Hate Crime Checklist Hate Crime Checklist Case # Email*Form will be sent to the email address entered below Victim Individual Legal name (Last, First): Other Names used (AKA): School, business or organization Name: Type:(e.g., non-profit, private, public school) Address: Faith-based organization Name: Faith: Address: Target of Crime:(Check all that apply) Person Private property Public property Other Target of Crime – OtherDescribe Nature of Crime: Bodily injury Threat of violence Property damage Other crime (Check all that apply)Other crimeDescribe Property damage – estimated value BiasType of Bias:(Check all characteristics that apply) Disability Gender Gender identity/expression Sexual orientation Race Ethnicity Nationality Religion Significant day of offense (e.g., 9/11, holy days) Other: Type of Bias – OtherDescribe Specify disability:(be specific)Actual or Perceived Bias – Victim’s Statement: Actual bias [Victim actually has the indicated characteristic(s)]. Perceived bias [Suspect believed victim had the indicated characteristic(s)]. If perceived, explain the circumstances in narrative portion of Report.Reason for BiasDo you feel you were targeted based on one of these characteristics? Yes No Explain in narrative portion of Report.Do you know what motivated the suspect to commit this crime? Yes No Explain in narrative portion of Report.Do you feel you were targeted because you associated yourself with an individual or a group? Yes No Explain in narrative portion of Report.Are there indicators the suspect is affiliated with a Hate Group (i.e., literature/tattoos)? Yes No Explain in narrative portion of Report.Are there Indicators the suspect is affiliated with a criminal street gang? Yes No Explain in narrative portion of Report.Bias Indicators (Check all that Apply): Hate speech Acts/gestures Property damage Symbol used Written/electronic communication Graffiti/spray paint Other: Describe with exact detail in narrative portion of Report.Bias Indicators – OtherDescribe HistoryRelationship Between Suspect & Victim:Suspect known to victim? Yes No If Yes, describe in narrative portion of ReportNature of relationship: Length of relationship: Prior reported incidents with suspect? Total # Prior unreported incidents with suspect? Total # Restraining orders? Yes No If Yes, describe in narrative portion of ReportType of order: Order/Case# WeaponsWeapon(s) used during incident? Yes No Type of weapon(s) used during incident Weapon(s) booked as evidence? Yes No Automated Firearms System (AFS) Inquiry attached to Report? Yes No EvidenceWitnesses present during incident? Yes No Statements taken? Yes No Evidence collected? Yes No Photos taken? Yes No Total # of photos: Taken by: ID #: Recordings: Video Audio Booked Suspect identified: Field ID By photo Known to victim ObservationsVICTIM Tattoos Shaking Unresponsive Crying Scared Angry Fearful Calm Agitated Nervous Threatening Apologetic Other observations: Other ObservationsDescribe SUSPECT Tattoos Shaking Unresponsive Crying Scared Angry Fearful Calm Agitated Nervous Threatening Apologetic Other observations: Other ObservationsDescribe ADDITIONAL QUESTIONS (Explain all boxes marked “Yes” in narrative portion of report):Has suspect ever threatened you? Yes No Has suspect ever harmed you? Yes No Does suspect possess or have access to a firearm? Yes No Are you afraid for your safety? Yes No Do you have any other information that may be helpful? Yes No Resources offered at scene: Yes No Type: MedicalVictim Declined medical treatment Will seek own medical treatment Received medical treatment Suspect Declined medical treatment Will seek own medical treatment Received medical treatment Medical Release form? Yes No Paramedics at scene? Yes No Unit # Name(s)/ID # Hospital Jail Dispensary Physician/Doctor Patient # Officer (Name/Rank) Date MM slash DD slash YYYY Officer (Name/Rank) Date MM slash DD slash YYYY Supervisor Advised (Name/Rank) Date MM slash DD slash YYYY