Gothic Liberation Front Incident Report

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Please fill in all fields, using "n/a" if an answer does not apply to your incident. If further information is needed, you will receive a reply within seven (7) days of your submission date.

Name:
Email Address:
What is your age?	13-18 19-24 25-30 31-35 36+
What is your subcultural identification?	Goth Emo Punk Skater Metal/Rocker Juggalo Other
What is your country of residence?
In what city and state/region?
What is your occupation?
What was the nature of the incident?	Verbal Assault Physical Assault Sexual Assault Employment Discrimination School Discrimination/Harassment Police Harassment Other Discrimination (retail, church, etc.)
What was the date of the incident?
In as much detail as possible, please describe the incident. Be sure to include witness names and location names. All information is kept strictly confidential.
Where the police notified?	Yes No
If so, which police department responded to the incident?
Do you feel you were treated fairly and your rights as a victim were properly observed?	Yes No
Police report number (if available)
In cases of school discrimination and harassment, do you feel that the school administration has responded properly to the issues?	Yes No
By clicking "Yes", I certify the all answers I have given are truthful and to the best of my knowledge. I understand by clicking "No" that my incident will de disregarded as a false report.	Yes No

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