Tell Your Story

This questionnaire is part of a project that we hope will educate the public on the effects of racial profiling by giving the victims of racial profiling a chance to speak out. Through these personal stories, we hope to generate publicity and give attention to the individuals whose everyday lives have been affected by the criminal justice system. For instance, with your express permission, we may use your story in a media campaign, for legislative testimony, or in litigation.

We will review all information provided. For this reason, it is necessary that you provide the most accurate account possible. Please be aware that should we decide to use your story, you will receive a request from us to use the information you have provided. All information will be kept confidential, however, and will not be disclosed without your permission.

	* Required information
First Name:	*
Last Name:	*
Address 1:
Address 2:
City:	State:
Zip/Postal Code:	*
Phone Number:
Fax number:
Other (pager, mobile, etc.)
E-mail address:	*
Race or Ethnicity:	*
Gender:	*

Date of Interaction with Law Enforcement:
Approximate Time of Interaction:
Approximate Location of Interaction:
Law Enforcement Agency Involved:
Officer Name(s):
Officer Badge Number(s):
Patrol Car Number(s):
Are You a Resident of the Jurisdiction in Which You Were Stopped?
Officer's Reason for Stop:
Was This a Legitimate Reason?
Were You Searched?
If Searched, Did Officer Ask for Consent?
If Officer Asked for Consent, Did You Agree to the Search?
If Searched, with Probable Cause?
If Searched, with a Warrant?
If Searched, were Drug Dogs Involved?
If Searched, was Contraband Found?
If Contraband was Found, what was it?
Was a Citation Issued?
Was a Warning Issued?
If a Warning was Issued, was if Verbal or Written?
Were you Arrested?
At Any Point During Your Interaction, Did You Get Into a Physical Altercation?
At Any Point During Your Interaction, Did You Get Into a Verbal Argument?
At Any Point During Your Interaction, Did You Run Away or Attempt to Run?
At Any Point During Your Interaction, Were You Physically Injured?
If Injured, Did You Seek Medical Attention?
If Injured, Do You Have Photos of the Injuries?
At Any Point During Your Interaction, Did You Ask for an Attorney?
Did You Retain an Attorney?
Were There Any Witnesses of Your Interaction?
Did you File a Written Complaint with the Law Enforcement Agency?