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

BBYO Affiliation

Name of BBYO chapter you are connected with: (If none, please list N/A)

City of the chapter:

State of the chapter:

Your Role:

What is your official role in the chapter?

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

PLEASE CHECK THE BOX THAT BEST DESCRIBES YOU:

I am 18 years of age or older (or an emancipated minor). I am under the age of 18. I understand that, in most circumstances, ADL and/or BBYO will not be able to take action on my behalf unless a parent or guardian is involved.

I understand that by submitting this form, the information I provide will be shared with ADL and BBYO separately for their respective review. I further understand that each organization will independently analyze the report to determine what follow-up, if any, may be appropriate by that organization, and that the organizations’ respective assessments may differ and even potentially conflict. I also agree that ADL and BBYO each have my permission to share information with each other about my matter, though I understand that they may not necessarily do so.

Please check this box if you are a minor.

Optional:  I agree that 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 Incident Reporting Terms and Conditions, which applies to my relationship with ADL only.

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

User Geolocation

Address & Map

Street Address

City/State

Zip / Postal Code

Country

Contact Information

Discord	Email	Facebook
Instagram	Pinterest	TikTok
Twitch	Twitter	Youtube
Not on Social Media	Zoom	Other