1-699 Hate Crime Incident Report

1-699 (Rev. 07-15-10)

OMB No. 1110-0015

HATE CRIME INCIDENT REPORT
ORI

Agency Name

/

Date of Incident

Incident No.

Month

/
Day

Year

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
06 Larceny-Theft
10 Intimidation
02 Forcible Rape
#1
#3
03 Robbery
07 Motor Vehicle Theft 11 Destruction/Damage/
Offense
# of victims
Offense
# of victims
04 Aggravated Assault 08 Arson
Vandalism
#4
#2
Location (Check one for Offense #1.)
47
Gambling Facility/Casino
01
Air/Bus/Train Terminal
18
Parking Lot/Garage
Bank/Savings and Loan
Rental Storage Facility
48
19
Industrial Site
02
Bar/Night Club
Residence/Home
49
Military Installation
20
03
50
Church/Synagogue/Temple
Park/Playground
21
Restaurant
04
05
51
Commercial/Office Building
Rest Area
School/College
22
06
Construction Site
23
Service/Gas Station
52
School-College/University
07
Convenience Store
53
School-Elementary/Secondary
24
Specialty Store (TV, Fur, etc.)
08
Shelter-Mission/Homeless
Department/Discount Store
Other/Unknown
54
25
55
09
Drug Store/Dr.'s Office/Hospital 37
Abandoned/Condemned Structure
Shopping Mall
Amusement Park
10
Field/Woods
38
Tribal Lands
56
Government/Public Building
11
39
Arena/Stadium/Fairgrounds/Coliseum
Grocery/Supermarket
40
Enter a Location for each offense having
12
ATM Separate from Bank
13
41
a different location than Offense #1:
Highway/Road/Alley/Street
Auto Dealership New/Used
14
42
Camp/Campground
Hotel/Motel/etc.
#2
15
44
Daycare Facility
Jail/Prison
#3
16
45
Dock/Wharf/Freight/Modal Terminal
Lake/Waterway
17
46
Farm Facility
Liquor Store
#4
Bias Motivation (Check one for Offense #1.)
Race
Religion
Disability
Anti-Physical Disability
11
Anti-Jewish
51
Anti-White
21
Anti-Catholic
Anti-Mental Disability
52
12
Anti-Black or African American 22
13
Anti-American Indian or
23
Anti-Protestant
Alaska Native
Anti-Islamic (Muslim)
24
14
25
Anti-Other Religion
Anti-Asian
15
Anti-Multiple Races, Group
26
Anti-Multiple Religions, Group
Anti-Atheism/Agnosticism
Anti-Native Hawaiian or
27
16
Enter a Bias Motivation for each offense
Other Pacific Islander
having a different bias motivation
Sexual Orientation
than offense #1:
Ethnicity
41
32
Anti-Hispanic or Latino
Anti-Male Homosexual (Gay)
#2
33
Anti-Not Hispanic or Latino
Anti-Female Homosexual (Lesbian)
42
#3
43
Anti-Homosexual (Gay & Lesbian)
Anti-Heterosexual
44
#4
Anti-Bisexual
45
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
#1

5
6
7
8

Offense
#2

Offense
#3

Offense
#4

Religious Organization
Society/Public
Other
Unknown
Total # of Victims

*Indicate the total number of individuals (persons) who were victims in the incident.
Number of Offenders

(Use "00" for Unknown Offender.)

Race/Ethnicity of Offender or Offender Group (Check one race and one ethnicity.)
Race
Group of Multiple Races
1
White
5
2
Black or African American
6
Unknown
7
Native Hawaiian or Other
3
American Indian or
Pacific Islander
Alaska Native
4
Asian

Ethnicity
H
Hispanic or Latino
Not Hispanic or Latino
N
M
Group of Multiple Ethnicities
U
Unknown

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 routine Summary UCR 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.
Provide the Agency Name, 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.
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. Society/Public is applicable only in the National IncidentBased Reporting System (NIBRS).
NUMBER OF OFFENDERS: Provide the number of offenders. 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/ETHNICITY OF OFFENDER OR OFFENDER GROUP: Provide the race/ethnicity of the offender or offender group.
If the number of offenders is entered as Unknown Offender, then the offender's race/ethnicity must also be indicated as Unknown.