Los Angeles Police Department HATE CRIME SUPPLEMENTAL REPORT Page BKG # of DR # Victim Type: Individual Legal name: Target of Crime (Check all that apply): Person (Last, First) Other Names used (AKA): School, business or organization Private property Public property Other: Name: Nature of Crime (Check all that apply): Type: Bodily injury Threat of violence (e.g., non-profit, private, public school) Property damage Address: Faith-based organization Name: Other crime: Faith: Property damage - estimated value: Address: Type of Bias: (Check all characteristics that apply): Actual or Perceived Bias - Victim's Statement Actual bias [Victim actually has the indicated characteristic(s)]. Disability Perceived bias [Suspect believed victim had the indicated characteristic(s)]. Gender If perceived, explain the circumstances in narrative portion of Report. Gender identity/expression Sexual orientation Reason for Bias: Do you feel you were targeted based on one of these characteristics? Race Yes Ethnicity No Explain in narrative portion of Report. Do you know what motivated the suspect to commit this crime? Nationality Yes Religion No Explain in narrative portion of Report. Do you feel you were targeted because you associated yourself with an Significant day of offense (e.g., 9/11, individual or a group? holy days) Yes No Explain in narrative portion of Report. Other: Are there indicators the suspect is affiliated with a Hate Group (i.e., literature/tattoos)? Specify disability (be specific): Yes No Describe in narrative portion of Report. Are there Indicators the suspect is affiliated with a criminal street gang? Yes No Describe in narrative portion of Report. Bias Indicators (Check all that apply): Hate speech Acts/gestures Written/electronic communication Property damage Graffiti/spray paint Symbol used Other: Describe with exact detail in narrative portion of Report. Relationship Between Suspect & Victim: Suspect known to victim? Yes Prior reported incidents with suspect? Total # No Prior unreported incidents with suspect? Total # Nature of relationship: Restraining orders? Length of relationship: If Yes, describe in narrative portion of Report. If Yes, describe in narrative portion of Report. Type of order: Weapon(s) used during incident? Yes No Weapon(s) booked as evidence? Yes No Automated Firearms System (AFS) Inquiry attached to Report? 03.01.05 (06/16) Yes Order/Case #: Type: Yes No No Los Angeles Police Department HATE CRIME SUPPLEMENTAL REPORT Page BKG # of DR # Witnesses present during incident? Yes No Statements taken? Evidence collected? Yes No Recordings: Photos taken? Yes No Suspect identified: Video Taken by: No Audio Field ID D #: Total # of photos: Yes Booked By photo Known to victim Serial #: VICTIM SUSPECT Tattoos Tattoos Shaking Shaking Unresponsive Unresponsive Crying Crying Scared Scared Angry Angry Fearful Fearful Calm Calm Agitated Agitated Nervous Nervous Threatening Threatening Apologetic Apologetic Other observations: Other observations: ADDITIONAL QUESTIONS (Explain all boxes marked "Yes" in narrative portion of report): Has suspect ever threatened you? Yes No Has suspect ever harmed you? Yes No Does suspect possess or have access to a firearm? Yes No Are you afraid for your safety? Yes No Do you have any other information that may be helpful? Yes No Resources offered at scene: Victim Yes No Suspect Type: Paramedics at scene? Name(s)/ID #: Declined medical treatment Hospital: Will seek own medical treatment Jail Dispensary: Received medical treatment Authorization to Release Medical Information, Form 05.03.00, signed? Yes Physician/Doctor: Yes No Patient #: Reporting Officer (Name/Rank) Date Serial # Division/Detail Reporting Officer (Name/Rank) Date Serial # Division/Detail Supervisor Approving (Name/Rank) Date Serial # Division/Detail 03.01.05 (06/16) No Unit #: