Incident Report Form
 
Please note: Although it is most unlikely that you will experience any problems responding to this form, certain non-standard browsers will not respond properly. If you experience any difficulties, (or if you are not using a forms-capable browser) you may email your response to this form to: khrn@khrn.org.

Please be as detailed as you can with the information you provide on this form. This information will be given to an investigator with KHRN. That person will contact you in person to discuss the details of the incident and work on possible solutions. ALL fields are required so please fill in every field.

Name:
(First)
(MI)
(Last)
Address1:
Address2:
City: State: Zip:-
Contact Phone:
(Day)
(Evening)
(Mobile)
Email:

I feel I was discriminated against for the following reason:

This discrimination happened at:
Work
In the Community
OTHER

The best time to contact me is:

These are the details of the incident I am reporting:

Details: