1-699 Hate Crime Incident Report

1-699 (Rev. 07-07-11)

Initial

OMB No. 1110-0015

HATE CRIME INCIDENT REPORT
Adjustment

ORI

Date of Incident

/
Month

/
Day

Year

Page
of
of Same Incident
Incident No.
Offense (Enter an offense code and number of victims for each bias-motivated offense.)
09 Simple Assault
05 Burglary
Offense
# of victims
Offense
# of victims
01 Murder
10 Intimidation
06 Larceny-Theft
#1
#4 Offense - # of victims 02 Forcible Rape
03 Robbery
07 Motor Vehicle Theft 11 Destruction/Damage/
#2
#5
04 Aggravated Assault 08 Arson
Vandalism
#3
Location (Check one for Offense #1.)
09
Drug Store/Dr.'s Office/Hospital
37
21
Restaurant
Abandoned/Condemned Structure
52
Air/Bus/Train Terminal
46
Farm Facility
School-College/University
01
10
Field/Woods
School-Elementary/Secondary
53
38
Amusement Park
Service/Gas Station
39
Arena/Stadium/Fairgrounds/
Gambling Facility/Casino/Race Track 23
47
Coliseum
Government/Public Building
54
Shelter-Mission/Homeless
11
12
Grocery/Supermarket
55
Shopping Mall
ATM Separate from Bank
40
24
Specialty Store (TV, Fur, etc.)
41
Auto Dealership New/Used
13
Highway/Road/Alley/Street
02
14
Hotel/Motel/etc.
56
Tribal Lands
Bank/Savings and Loan
25
Other/Unknown
03
Bar/Night Club
48
Industrial Site
42
Camp/Campground
15
Jail/Prison
Enter a Location for each offense having
16
04
Church/Synagogue/Temple/Mosque
Lake/Waterway
a different location than Offense #1:
05
Liquor Store
17
Commercial/Office Building
49
Military Installation
57
Community Center
#2
Construction Site
18
Parking Lot/Garage
06
Park/Playground
50
#3
07
Convenience Store
44
19
Rental Storage Facility
Daycare Facility
#4
20
Residence/Home
08
Department/Discount Store
Rest Area
45
Dock/Wharf/Freight/Modal Terminal 51
#5
Bias Motivation (Check up to five for Offense #1.)
Gender
Race
Religion
Anti-White
11
21
Anti-Jewish
61
Anti-Male
12
22
Anti-Black or African American
Anti-Catholic
Anti-Female
62
Anti-Protestant
Gender Identity
Anti-American Indian or
23
13
71
Alaska Native
Anti-Transgender
Anti-Islamic (Muslim)
24
Anti-Other Religion
72
Anti-Gender Non-Conforming
Anti-Asian
14
25
Anti-Multiple Religions, Group
26
Enter up to five Bias Motivations
15
Anti-Multiple Races, Group
27
for each offense having a different
Anti-Atheism/Agnosticism
Anti-Native Hawaiian or
16
Sexual Orientation
Other Pacific Islander
bias motivation than Offense #1:
Ethnicity
Anti-Gay (Male)
41
#2
42
32
Anti-Hispanic or Latino
Anti-Lesbian
#3
33
43
Anti-Lesbian, Gay, Bisexual, or
Anti-Not Hispanic or Latino
Disability
Transgender (Mixed Group)
#4
Anti-Physical Disability
44
51
Anti-Heterosexual
#5
Anti-Mental Disability
45
Anti-Bisexual
52
Victim Type (Check all applicable victim types for each offense listed above.)
Offense
#1

1
2
3
4

Individual*
Business
Financial Institution
Government

Offense
#2

Offense
#3

Offense
#4

Offense
#5

Offense
#1

Offense
#2

Offense
#3

Offense
#4

Offense
#5

5 Religious Organization
7 Other
8 Unknown
Total # of victims

Total # of victims 18 and over

Total # of victims under 18

*Indicate the total number of individuals (persons) who were victims in the incident.
Total # of offenders 18 and over

Total Number of Offenders

Total # of offenders under 18

(Use "00" for Unknown Offender.)

Race and Ethnicity of Offender or Offender Group (Check one race and one ethnicity.)
Race
Ethnicity
Group of Multiple Races
1
White
5
H
Hispanic or Latino
2
Black or African American
6
Unknown
N
Not Hispanic or Latino
American Indian or
3
7
Native Hawaiian or Other
M
Group of Multiple Ethnicities
Pacific Islander
Unknown
Alaska Native
U
4
Asian

INSTRUCTIONS FOR PREPARING QUARTERLY HATE CRIME REPORT AND HATE CRIME INCIDENT REPORT

This report is authorized by Title 28, Section 534, U.S. Code, and the Hate Crime Statistics Act of 1990. Even though you are
not required to respond, your cooperation in using this form to report hate crimes known to law enforcement during the quarter
will assist the FBI in compiling timely, comprehensive, and accurate data regarding the incidence and prevalence of hate crime
throughout the Nation. Please submit this report quarterly, by the 15th day after the close of the quarter, and any questions to
the FBI, Criminal Justice Information Services Division, Attention: Uniform Crime Reports/Module E-3, 1000 Custer Hollow
Road, Clarksburg, West Virginia 26306; telephone 304-625-4830, facsimile 304-625-3566. Under the Paperwork Reduction
Act, you are not required to complete this form unless it contains a valid OMB control number. The form takes approximately
7 minutes to complete. Instructions for preparing the form appear below.
GENERAL
This report is separate from and in addition to the traditional Summary Reporting System submission. In hate crime reporting, there
is no Hierarchy Rule. Offense data (not just arrest data) for Intimidation and Destruction/Damage/Vandalism of Property should be
reported. On this form, all reportable bias-motivated offenses should be included regardless of whether arrests have taken place.
Please refer to the publication Hate Crime Data Collection Guidelines for additional information.
QUARTERLY HATE CRIME REPORT
At the end of each calendar quarter, each reporting agency should submit a single Quarterly Hate Crime Report , together with
an individual Incident Report for each bias-motivated incident identified during the quarter (if any). If no hate crimes occurred
during the quarter, the agency should submit only the Quarterly Hate Crime Report .
The Quarterly Hate Crime Report should be used to identify your agency, to state the number of bias-motivated incidents being
reported for the calendar quarter, and to delete any incidents previously reported that have been determined during the reporting
period not to have been motivated by bias.
HATE CRIME INCIDENT REPORT
The Incident Report should be used to report a bias-motivated incident or to adjust information in a previously reported incident.
Include additional information on separate paper if you feel it will add clarity to the report.
Indicate the type of report as Initial or Adjustment. Provide the Originating Agency Identifier (ORI) and Date of Incident.
INCIDENT NUMBER: Provide an identifying incident number, preferably your case or file number.
UCR OFFENSE: Provide codes for all offenses within the incident determined to be bias motivated and the number of victims
for each offense. In multiple offense incidents, report only those offenses determined to be bias motivated. Should more than five
bias-motivated offenses be involved in one incident, use additional Incident Reports and make an appropriate entry in the
Page
of
portion of each form.
LOCATION: Provide the most appropriate location of each bias-motivated offense.
BIAS MOTIVATION: Provide the nature of the bias motivation for each bias-motivated offense.
VICTIM TYPE: Provide the type of victim(s) identified within the incident. Where the type of victim is Individual, indicate the
total number of individuals (persons) who were victims in the incident, the total number of victims 18 and over, and the total number
of juvenile victims, which are persons under the age of 18. Society/Public is applicable only in the National Incident-Based
Reporting System.
TOTAL NUMBER OF OFFENDERS: Provide the number of offenders, the total number of offenders 18 and over, and the
total number of juvenile offenders, which are persons under the age of 18. Incidents involving multiple offenders must not be coded
as Unknown Offender. Indicate an Unknown Offender when nothing is known about the offender including the offender's race.
When the Race of Offender(s) has been identified, indicate at least one offender.
RACE AND ETHNICITY OF OFFENDER OR OFFENDER GROUP: Provide the race and ethnicity of the offender, if
known. If there was more than one offender, provide the race and ethnicity of the group as a whole. If the number of offenders
is entered as Unknown Offender, then the offender's race and ethnicity must also be indicated as Unknown.