What happened: my record
A printable from Coping With Racism and Hate. Fill it in by hand. Nothing you write is collected by this website.
What happened: my record
Date: __________ Time: __________ Place (address or school): ______________________________
What was said or done (exact words if you can):
Who did it (name or description): ______________________________ Witnesses (names and phone numbers): ______________________________
Proof I saved: [ ] screenshots [ ] photos [ ] messages [ ] other: __________
Who I told: [ ] Teacher or principal, date: __________ [ ] Police, report number: __________ [ ] Civil Rights Department, date: __________ [ ] Counselor or pastor
How I feel today (1 = okay, 5 = very upset): 1 2 3 4 5
Help: 211 for local help. CRD 800-884-1684. County lines: San Mateo (800) 686-0101, Santa Clara (800) 704-0900 press 1. In danger, call 911. Do not write your immigration status on this sheet.
From Coping With Racism and Hate. Facts checked October 21, 2026. Free information, not legal or medical advice.