Incident Form for Somali Islamic Ctr
Somali Islamic Ctr

IF THIS IS AN EMERGENCY, DIAL 9-1-1

All the information you share with us will be private and confidential. This form takes 5 minutes to complete.

Fields with a star* are required.

Quick Links:
  1. Hate Crime Guide from the DOJ
  2. Mental Wellness Hub

The Form is a standardized online form for the public to use to report threats, incidents, or suspicious activity related to Muslim community members, organizations, or community groups in Colorado. It was developed in partnership with many Muslim organizations in our community, including Muslim Family Services of Colorado.

Anti-Muslim sentiment is on the rise in Colorado and impacts the safety and well-being of our community members. It is imperative that we document all bias incidents perpetrated against our community in order improve safety and security in Colorado. We can reference the aggregate data when reporting to law enforcement and asking our elected officials to enact policies. We can also use this data to identify trends and track hate crimes.

The incident data collected will be used in aggregate form (to protect privacy) and identify how to improve the safety and security of our community. All personal identifying information will be kept confidential and protected by Somali Islamic Ctr.

This Form does not replace a report to local authorities. We encourage you to report the incident here, and to connect with Muslim Family Services of Colorado to receive victim services and advocacy when contacting local authorities. We also have a Mental Wellness Hub accessible to the Muslim community in Colorado.

You may also reach out to the national Council on American Islamic Relations for access to legal services when reporting a hate crime.

Information about the victim of the incident.
If you wish to remain anonymous, leave blank
(e.g. "Me, friends, family, etc")
Time and Place of Incident
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What type of incident happened?* (Select All that Apply)
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    •   , phone message, phone call, etc.
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    •   /Directed Use of Obscenities
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Incident Details

Who was or were all the offender(s) in this incident?*

  •    (friend, community member, etc)
  •    a complete stranger
  •    a member of my family
  •    a person in a position of trust (example: police officer, teacher, medical provider, etc.)
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What actions were taken in response?* (Select all that apply)

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  •   , and/or other Mental Health Services
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Incident Consequences

What consequences have you faced as a cause of this incident?*

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  •    and physical problems
  •    and physical problems
  •    health impact and trauma
  •    health impact and trauma

Please tell us more about these consequences. (Select all that apply)*

  •    material damages
  •    permanently
  •    my home temporarily
  •    my school permanently or temporarily
  •    medical services
  •    mental health services
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  •    measures for my safety (obtained guns, self-defense classes, security cameras, and systems, etc.)
  •    a place I frequented and/or liked
  •    in strangers and people I know
  •    and acquaintances as a result of this incident
Follow-up

What would you like to see happen as a result of completing this form?

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  •    an email of services/resources available
  •    I need and I would like to talk to someone.

Our ability to perform timely 1:1 followups may be limited due to capacity.

Summary

Thank you for sharing your story with us. If you are interested in getting connected to resources, please enter your email address below (please note, if your name is in your email, you will no longer be anonymous). Our Staff will respond to you within 48 hours inshaAllah.

If you would like some resources to help you cope with adversity immediately, we have created a Wellness Hub to support your needs during times of adversity.

If you wish to remain anonymous, leave blank. Please note that if you leave this blank, we cannot contact you.