POLICE INCIDENT REPORT FORM
If you or someone you know has been stopped because of your immigration status, national origin, or race, please take a moment to
provide us with all the information. The personal information is completely confidential and it will not be shared without your
permission. We need to compile the story of every incident to determine cases of discrimination. Once you have completed the
questionnaire, please contact the ACLU: 617-482-3170 or MIRA Coalition at: (617) 350-5480 Ext. 206 / [email protected].
I. Personal Information
.
Information about the person, who was stopped, detained or arrested:
1. Name:
2. Address:
3. Phone Number:
4. Country of Origin:
5. Immigration status:
(undocumented /visa type / resident /US citizen)
If you are filling this out for somebody else, please indicate:
6. Your Name:
7. Your contact information (name/ phone/ email/ if you represent an organization):
II. Description of Incident
1. Explain in your own words what happened:
2. Date of incident:
3. Time of day:
4. Location (be as precise as possible, such as “corner of Tremont St. and School St. in Boston”):
.
POLICE INCIDENT REPORT FORM
If you or someone you know has been stopped because of your immigration status, national origin, or race, please take a moment to
provide us with all the information. The personal information is completely confidential and it will not be shared without your
permission. We need to compile the story of every incident to determine cases of discrimination. Once you have completed the
questionnaire, please contact the ACLU: 617-482-3170 or MIRA Coalition at: (617) 350-5480 Ext. 206 / [email protected].
5. Police Department: (local/state, if police department is not known, describe what the officer was wearing, or any other
details that might help us figure out what police department stopped you).
6. Police Officer’s name (if known):
7. Officer’s badge number (if known):
8. Were you pulled over in your vehicle? _____YES _____NO
8.1. Did the officer give a reason for the stop? _____YES _____NO. If so, what reason?
9.
8.2. Were you the driver or the passenger?
Were you arrested? ____ YES ____NO
9.1. What was the reason for the arrest?
9.2.
What were the charges against you?
10. Did you go to a police office? ____ YES ____ NO
10.1. Which police office?
11. Did you go to court? ____YES ____ NO
11.1. Which court?
11.2. What happened in court?
11.3. Did you pay a fine, a fee, or bail?
11.4. Did they give you any future court dates? When?
11.5. Are there any charges pending against you at this time?
11.6. Did Immigration (ICE) issue a detainer against you?
___ YES ___ NO ___ DON’T KNOW
11.7. Where you detained by Immigration (ICE) afterwards?
___ YES ___ NO ___ DON’T KNOW
11.8. How many hours/days were you in detention?
11.9. Has Immigration (ICE) given you any documents? _____YES _____NO. What are the titles of
those documents? -Please attached copies of the documents-
III. Background
1.
2.
3.
4.
5.
6.
Have you ever had any dealings with the police before?
Have you ever been in court before?
Do you have any convictions anywhere in the United States?
Have you ever been arrested anywhere in the United States?
Have you been ordered deported before?
Do you have a lawyer representing you?
6.1. If so, what is the lawyer’s name?
.
____ YES
____ YES
____ YES
____ YES
____ YES
____ YES
____ NO
____ NO
____ NO
____ NO
____ NO
____ NO