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UNDER THE BRIDGE - About - Newspaper - Photo archive - Contact Us - Word On the Street - Links - |
Return this abuse report to:
| Under The Bridge P.O. Box 3431 Manchester, NH 03105 (603) 665-9133 Fax: (603) 428-7945 |
This document will be
archived at: The National Coalition for the Homeless 1012 14th Street Suite 600 Washington, DC 20005 |
| INCIDENT REPORT
FORM FOR VIOLENCE OR HARASSMENT OF PERSON EXPERIENCING HOMELESSNESS |
The purpose of this form is to assist advocates
and people experiencing homelessness in tracking cases of abuse
and mistreatment.
Contact Information of Victim (optional)
Name
___________________________________________________________________
Address (or way to contact)
________________________________________________________________________
________________________________________________________________________
| Number: _________________________ | Email: _________________________ |
Incident Location
Date and Time
____________________________________________________________
Location: Be as specific as possible, for example, on the corner
of 14th and K between the metro entrance and the coffee stand.
________________________________________________________________________
________________________________________________________________________
Injuries/Losses/Grievances, e.g. assault, arrest,
destruction or confiscation of property
________________________________________________________________________
________________________________________________________________________
Description of Incident: Include as many factual
details as possible e.g. any police response and any witness
information.
| If applies: Officer's Name: _______________ | Badge Number: _______________ |
________________________________________________________________________
________________________________________________________________________
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