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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