URJ Affiliation

Name of URJ synagogue you are connected with:

City of synagogue:

State of synagogue:

Your Role:

What is your official role in the synagogue?

I agree that URJ and/or ADL may contact the synagogue I am connected with about this incident.

Incident Details

What happened?

Other

I believe I was discriminated against because of my actual or perceived:

Date of Incident

Incident Description

What remedy/solution are you seeking?

This was something that...

OPTIONAL: Have you contacted any law enforcement agency regarding this matter?

OPTIONAL: Which agency?

Please be advised that ADL is neither a legal services agency nor a law enforcement agency. All potential criminal incidents should also be reported to local, state, or federal authorities, as appropriate. If you are fearful of reporting to police for any reason, please consider referring to this list of community support agencies/organizations.

Photo, video, or other file from incident:

Your Contact Info

First Name

Last Name

Phone Number (needed for a quick response)

Postal Code of Residence

Optional: I agree that for purposes of investigation, ADL may use my name when making inquiries, including inquiries directly to the person or entity who allegedly committed the act(s).

I agree to ADL's terms and conditions, as articulated here .

User Geolocation

Address & Map

Street Address

City/State

Zip / Postal Code

Country

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