POLICE ACTION INTAKE FORM R etu rn to:
W e b sit e:
A C L U o f So u t h C a ro l i n a In t ak e P O Bo x 209 98 Ch a rle ston , S C 294 13 -09 9 8 w w w . a cl us o ut h ca ro l i na . o r g
T el l u s ab o u t q u es t i o n ab l e t ra f fi c , p ed es t ri an o r s h o p pin g in cid ents . By fillin g o u t thi s fo r m y o u ar e h el p i n g t h e A m e ri c an Ci v i l Li b e rt i es Un i o n o f So u t h Ca ro l i n a co l l e ct mu ch -n e ed ed d a t a a b o u t the p r ev ale nc e , p att er ns , a nd c ha r ac te risti cs of r a ci al o r eth ni c pr ofil ing b y sta te , coun ty and l oc al p oli ce ag en ci es . Pl e as e b e as s u r ed t h a t al l p e rs o n al i n fo r m at i o n co l l e ct ed w i l l b e k e p t s t ri ct l y co n fi d en t i al . W e c an n o t p r o mis e y o u t h e i n fo r m atio n y o u p ro v id e w ill l e ad to an y s p e ci fi c a ctio n o n A C L U ’ s p a rt . It i s p ossi ble t hat y ou m ay r e c eiv e a re q u es t f ro m th e A C LU to u se t he in fo r m atio n you h av e p ro v id ed f or o ne o r mo r e of t h e fol l o wi n g p u rp os es : (1 ) le g is l ativ e t esti m o n y; (2 ) litig ati o n (3 ) tellin g you r sto ry t o th e m ed ia . W e wi l l no t do s o w i th o ut y o u r p er m i s s i o n. I N CI D E N T N U M B E R # _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ( A s s i g n e d b y A C L U ) INFORMATION ABOUT THE PERSON COMPLAINING First Name: ___________________________________ Last Name:_____________________Gender:_______________ Street Address:_________________________________________________Race/ethnicity:_______________________ City:____________________________ State:____________________________ Zip:_____________________________ Home Phone:_____________________
Office Phone:_____________________ Martial status:____________________
Other contact info (email, pager, mobile):________________________________________________________________ Date of birth:_________________________________________ Occupation:___________________________________ What languages do you speak? _________________________Country of origin:_________________________________ Are you a US citizen?_______________________If no, country of citizenship__________________________________ Immigration status?_________________________ How long have you lived in US?______________________________ Location and legal status of other family members living in US:______________________________________________ ________________________________________________________________________________________________ Name and contact information of someone who would always know how to reach you:_______________________ __________________________________________________________________________________________ Interviewer, if form completed by someone other than the person complaining:_____________________________ Date form completed:
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Incident #______________________(to be assigned by ACLU) Type of Incident: _________Traffic _______Pedestrian _______Shopping _______Other (explain)_________________ City & State of incident:________________________ Date (mm/dd/yy):______________________ Time:___________
If traffic stop, describe the car you were driving, including the make, model, year and state of registration, if known. __________________________________________________________________________________________________ __________________________________________________________________________________________________ Did the car have noticeable bumper stickers?______________________________________________________________ __________________________________________________________________________________________________ Describe the events of the incident with as much detail as possible. What were you doing when approached by the officer? __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Why did the officer tell you that you were stopped?________________________________________________________ __________________________________________________________________________________________________ Did the officer ask if you spoke English?_________________________________________________________________ Did you understand the officer’s questions and instructions in English?_________________________________________ Did you ask the officer to address you in a language that you understood?_______________________________________ Were you offered an interpreter or translated materials?-_____________________________________________________ Where were you (on sidewalk, highway, in front of building)? If traffic stop, what were your travel plans (point of origin & destination & purpose)?____________________________________________________________________________ __________________________________________________________________________________________________ Were you searched or questioned?____________________________________________________________________ Was your ID, license and registration checked? _________________________________________________________ Did the officer ask for any other documents such as a passport or green card?___________________________________ Did the officer ask you what country you are from?________________________________________________________ Did the officer report contact with ICE?____________________________________________________________ Were your passengers also searched or questioned?________________________________________________________ Were your passengers asked for any documents?_________________________________________________________ ________________________________________________________________________________________________
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Were you cited, ticketed, given a warning, or arrested ? For what? What was the result? ___________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ If you were arrested, did you have contact with anyone from ICE at the jail?_____________________________________ If you refused a search, did the officer take additional action? If you consented to a search, what happened? Was anything found (e.g. illegal contraband such as weapons or drugs)? ___________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ What agency was the officer affiliated with (e.g. local police, state trooper, etc)? Can you list names of the officer(s) who stopped you and names of witnesses? ___________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Do you believe you were targeted based on characteristics such as your race or national origin or language? Please explain your answer._______________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Did the officer specifically say or do anything to make you believe race, national origin, or language played a role? __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Did you make a complaint to anyone about this incident? ___________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ If yes, to whom did you make the complaint? What was the response? _________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________
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How long were you engaged with the officer? Did the incident significantly disrupt your plans? _____________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ How has this made you feel? __________________________________________________________________________ __________________________________________________________________________________________________ Are you doing anything differently now? ________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Are you related to anyone who has been deported recently?________________________________________________ ______________________________________________________________________________________________ Have you been stopped by the police more than once in the last two years?__________________________________ If you have, please fill in a separate report like this one for each incident. Thank you. USES OF THIS REPORT: We may use your report to advocate legislative measures that will protect individuals from racial or ethnic profiling and to identify jurisdictions where we may challenge racial or ethnic profiling in court. It is possible that you may receive a request from the ACLU to use the information you have provided for one or more the following purposes: (1) legislative testimony; (2) litigation; or (3) telling your story to the media. We will not do so without your permission
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