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Bias Crime

Bias Crime

Instructions: Answer the following questions to file a Bias Crime complaint with the Division of Criminal Justice

TO REPORT AN EMERGENCY, CRIME, ACCIDENT, INJURY, FIRE OR OTHER OCCURRENCE THAT REQUIRES AN EMERGENCY RESPONSE
CALL 9-1-1

General Information
Documents

Did this incident occur in New Jersey?

Did this incident occur in New Jersey? Yes
Did this incident occur in New Jersey? No

Did this incident occur in the workplace?

Did this incident occur in the workplace? Yes
Did this incident occur in the workplace? No

Was this incident bias related?

Was this incident bias related? Yes
Was this incident bias related? No

Please select the appropriate box(es)

Sexual Orientation

Race

Gender

National Origin

Religion

Gender Identity or Expression

Color

Ethnicity

Disability

Location and Date/Time of Incident

Street 1

*

Street 2

*

City

*

County

State

Zip

*

Date

*

Time (hh:mm am/pm)

*

Have you submitted a bias incident referral to this site in the past 90 days?

Have you submitted a bias incident referral to this site in the past 90 days? Yes
Have you submitted a bias incident referral to this site in the past 90 days? No

Was the incident a result of an ongoing dispute involving property?

Was the incident a result of an ongoing dispute involving property? Yes
Was the incident a result of an ongoing dispute involving property? No

Was the incident a result of a motor vehicle incident?

Was the incident a result of a motor vehicle incident? Yes
Was the incident a result of a motor vehicle incident? No

Did this incident occur at a religious institution?

Did this incident occur at a religious institution? Yes
Did this incident occur at a religious institution? No

If yes, name of religious institution

*

Address of religious institution

*

Did this incident occur in a place of public accommodation?

Did this incident occur in a place of public accommodation? Yes
Did this incident occur in a place of public accommodation? No

If yes, name of public accommodation

*

Address of public accommodation

*

Was the incident reported to the police?

Was the incident reported to the police? Yes
Was the incident reported to the police? No

If so, report number

*

Name of the police station where report was filed

*

Did the incident involve an organized hate group?

Did the incident involve an organized hate group? Yes
Did the incident involve an organized hate group? No

If yes, name of the hate group

*

Please describe your incident in detail

*

Contact Information

Would you like to remain anonymous?

Street 1

*

Name

*

Street 2

*

Email Address

**

City

*

Phone Number

*

County

Cell Number

*

State

Zip

*

Agency/Business/Organization Name

If applicable, please fill out the following information.

Agency/Business/Organization Name

*

Street 1

*

Organization Contact Name

*

Street 2

*

Organization Phone #

*

City

*

Organization Email Address

**

County

Occupation/Title

*

State

Zip

*

Visitor ID

*

Request ID

*

IP Address

*

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