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Report a Crime

Reports of LGBT hate crimes and violence help KCAVP staff track hate crimes and bias-related incidents. This information will only be used to collect data in order to find out what is going on in the community unless you tell us that you want to be contacted for further assistance. You may choose to remain anonymous and do not have to provide us with information that would reveal your identity.

Complete this form if you have been the victim or have personal knowledge of LGBT hate related harassment, property damage, or violence.

All information you provide is STRICTLY CONFIDENTIAL and will not be shared with anyone else including law enforcement. If the primary target of the attack was an institution or organization, enter that information.

Note: if there was one more than victim, complete and submit this online form for each victim.

General Information
How were you involved?
If other, please specify:
How were you referred to KCAVP?
Please provide additional information for the question above::

Victim Information
Victim's name:
Were you the victim?	Yes No
Victim's city:
Victim's county:
Victim's state:
Victim's age:
Victim's gender identity:
If other, please specify:
Victim's sexual orientation:
If other, please specify:
Victim's race:
If other, please specify:
Extent of injuries:
Please describe the injuries:
Medical attention reqiured:

Incident Information
Date of incident:
Time of incident:
Location of incident:
Street Address of incident:
Site type:
If other, please specify:
Bias motive:	Anti LGBT/Heterosexist HIV related Anti-transgender Disability Economic Religious Sexist Other
If other, please specify:
In your own words, please tell us what happened, in as much detail as possible:
Have you reported this to law enforcement?	Yes No
If yes, which law enforcement agency?

Offender Information
Number of offenders:
Was a vehicle used?	Yes No
Please describe make, model, color and license plate if known:
Relationship of the offender(s) to the victim:
If other, please specify:
Describe the offender(s) (take into consideration age, sex, ethnicity, height, build, tattoos, and clothing):

Your Contact Information
Would you like us to contact you about this incident?	Yes No
If you would like to be contacted by a KCAVP Victim Advocate, please provide your contact information below
Your name:
Phone number:
Email address:
Any other comments:

Need Help? Call KCAVP at 816-561-0550.

Report a Crime

Complete this form if you have been the victim or have personal knowledge of LGBT hate related harassment, property damage, or violence.

All information you provide is STRICTLY CONFIDENTIAL and will not be shared with anyone else including law enforcement. If the primary target of the attack was an institution or organization, enter that information.

Note: if there was one more than victim, complete and submit this online form for each victim.

General Information

How were you involved?

Select Victim Witness Parent Partner Friend Service Provider Perpetrator Other

If other, please specify:

How were you referred to KCAVP?

Select Police Friend Hospital (which one) Phone Book Court Media (which one) KCAVP Publicity Service Provider Other (specify) Unkown

Please provide additional information for the question above::

Victim Information

Victim's name:

Were you the victim?

Yes No

Victim's city:

Victim's county:

Victim's state:

Victim's age:

Victim's gender identity:

Select Male Female Transgender M-F Transgender F-M Queer Other

If other, please specify:

Victim's sexual orientation:

Select Gay Lesbian Bisexual Questioning/Unsure Unknown Other

If other, please specify:

Victim's race:

African American/black Arab/Middle Eastern Asian/Pacific Islander Latino/a Multiracial White/Caucasian Other

If other, please specify:

Extent of injuries:

Select No Injuries Minor injuries (example cuts, bruises, scratches) Serious injuries (example broken bones, surgery required) Death Unknown

Please describe the injuries:

Medical attention reqiured:

Select None Required Needed but not received Outpatient (Clinic or ER) Hospitalization (Inpatient) Unknown

Incident Information

Date of incident:

JanFebMarAprMayJunJulAugSepOctNovDec 12345678910111213141516171819202122232425262728293031 2008200920102011

Time of incident:

123456789101112 00051015202530354045505560 AM PM

Location of incident:

Street Address of incident:

Site type:

Select LGBT bar/club LGBT cruising area LGBT institution (non-bar) Police precinct/jail/vehicle Private residence Public place (store, restaurant) School or college Street Workplace Other

If other, please specify:

Bias motive:

Anti LGBT/Heterosexist

HIV related

Anti-transgender

Disability

Economic

Religious

Sexist

Other

If other, please specify:

In your own words, please tell us what happened, in as much detail as possible:

Have you reported this to law enforcement?

Yes No

If yes, which law enforcement agency?

Offender Information

Number of offenders:

12345678910 More than 10

Was a vehicle used?

Yes No

Please describe make, model, color and license plate if known:

Relationship of the offender(s) to the victim:

Select Friend/Acquaintance Employer or Co-Worker Landlord/Tenant/Neighbor Law Enforcement Partner/Boyfriend/Girlfriend Pick-Up Relative/Family Roommate Service Provider Stranger Other

If other, please specify:

Describe the offender(s) (take into consideration age, sex, ethnicity, height, build, tattoos, and clothing):

Your Contact Information

Would you like us to contact you about this incident?

Yes No

If you would like to be contacted by a KCAVP Victim Advocate, please provide your contact information below

Your name:

Phone number:

Email address:

Any other comments:

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Need Help?
Call KCAVP at 816-561-0550.