Tri-Town Discriminatory Incident Report
The questions contained on this form are used to gather information regarding you/your child/your family's experience. Thank you for taking the time to share this sensitive information with TTAR. 

This information will be used to gather data, establish patterns, highlight deficits, and for reporting purposes. Please note that TTAR is not affiliated with any government entity or official reporting authority, and completing this form does not replace reporting this incident to the establishment where the incident occurred. TTAR highly encourages you to report this incident to the proper authority. 

Your personal identifying information will NOT be shared outside of TTAR, although non-identifying details may be shared with the affiliated authority. (example: business owners, managers on duty, school administration and/or at school committee meetings, retail management, police department)
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1) Your Name (optional)
2) Name of child/family member/friend involved (optional)
3) Date of incident
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/
DD
/
YYYY
4 )Time of incident
Time
:
5) Location of incident
6) Town where incident occurred:

7) Please provide details of the incident:
8) Did you report this incident to anyone? 
9) If you answered "yes" to question 8, to who(m) did you report it to?
Did this incident involve a public servant/employee of a city/town?
Clear selection
10) If you would like a TTAR representative to contact you, please provide your email or phone number and your name.
11) This incident involved (please check all that apply):
12) Is there any other information you would like to share about your family or this incident that will help us better support you through this process?
13) How did you hear about this incident reporting mechanism?
14) Was this incident school related? 
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15) Grade of child/family members involved if this incident happened at school or at a school sponsored event
16) Which School did this incident happen at?
Clear selection
17) Was the incident reported to adult in charge/school? If so, when was report made and to whom?
18) Is this the first incident your child has experienced at this location/school?
Clear selection
By checking 'yes' you agree to the following terms:

The voluntary information you provide will be used to gather data, establish patterns, highlight deficits, and for reporting purposes. TTAR is not affiliated with any government entity or official reporting authority, and completing this form does not replace reporting this incident to the establishment where the incident occurred.

Your personal identifying information will NOT be shared outside of TTAR without your consent, although non-identifying details may be shared with the affiliated authority. 
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Required
I am at least 13-years old. *
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