Project LUNA Incident Reporting Form
Report Information
Thank You for Your Report. Thank you for taking the time to report a transphobic incident. Your information helps Project LUNA better understand and address unacceptable behaviours in venues, contributing to the creation of safer, more inclusive spaces for everyone. If you have any questions about this form or need assistance in completing it, please contact us at info@projectluna.co.uk. How We Store and Use Your Data All information provided in this form will be stored securely and in line with data protection regulations. We will retain this data for five years to support ongoing efforts to monitor, respond to, and prevent future incidents. By completing and submitting this form, you are giving Project LUNA permission to securely store this information and to take appropriate action based on the report, which may include sharing anonymised data with relevant partners (such as venues or universities) where necessary and appropriate. A Note on Wellbeing We understand that completing this form may be distressing or triggering. If you need support at any point, we encourage you to access the support resources linked at the end of this form. Your wellbeing matters to us.
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Reporter Information
(If you wish to remain anonymous or to use a pseudonym, you may do so. Leaving certain fields blank is acceptable; however, providing contact information allows us to follow up for clarification if needed.)
Name (or Pseudonym)
First Name
Last Name
Pronouns
Preferred Contact Method
Phone
Email
Other
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Affiliation to the incident
The targeted individual (victim)
Witness
Friend / Ally reporting on behalf of someone else
Venue staff / organiser
Other
Are you a student or from the community?
Non student Community
Student
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Incident Snapshot
(Please provide as many details as you can remember. If you need more space, attach additional pages labelled “Section 2 – Continued.”)
Date of incident
-
Month
-
Day
Year
Date
Approximate time of incident
Venue Name
Venue Address / Location within the Venue
Specific area E.g. Main stage, restroom, bar area.
Type of Venue
Bar / Club
Café / Restaurant
Concert / Performance Space
Community Center
Retail Store
Other
Was this is a ticketed / event - specific gathering
Yes
No
If yes: Name of Event
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Description of the Incident
(Use objective language and include specific quotes/phrases if possible.)
Which form of discrimination have you experienced? (Check all that apply)
Race
Religion
Sex
Sexuality
Age
Disability
Gender
Pregnancy and Maternity
Describe in detail what happened
Who said or did what? How did the incident unfold? What was said, done, or displayed?
Was there physical contact or threat of violence?
Yes
No
If Yes, please describe.
Did the incident involve any of the following? (check all that apply):
Verbal harassment (slurs, insults, jokes)
Physical intimidation or assault
Display of transphobic imagery or signage
Cyberbullying (e.g. Posts on social media related to the venue)
Denial of Service (E.g. refusal to serve / assist due to gender identity)
Other
Approximate number of people directly involved (including target, perpetrator(s), and any others.
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Individuals Involved
Perpetrator(s)/Offender(s) (if known):
Name(s)
Description
approximate age, clothing, distinguishing features, role—e.g., “bartender,” “security guard,” “patron,” “performer”
Targeted Individual(s) (victim’s) Information (if different from Reporter):
First Name
Last Name
Contact Info (Optional)
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Evidence and Documentation
Physical Evidence
Photographs (e.g. signs, messages, injuries)
Video Footage (e.g. phone recordings, security cameras)
Audio recordings
Screenshots (e.g. social media posts, text messages)
Venue security log book or incident report (if allowed to obtain)
Other
No evidence available (this is okay!)
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Briefly describe what each evidence item shows (if applicable):
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Impact Statement
How did this incident affect you (or the targeted individual)? (e.g., emotional distress, physical harm, inability to enjoy the venue, need for medical attention):
Were any medical or mental health services sought?
Yes
No
If yes: Please describe
Did you report the incident to the venue
Yes
No
If No: Why
If Yes: Specify to whom and on what date: What was the outcome and were you happy with outcome?
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Follow Up
Next Steps for Project LUNA - We may contact you for additional information regarding your report. We will discuss the report with the venue as part of our follow-up process.
If you are a student, do you give permission for us to share relevant information (anonymously) with your university’s reporting systems? *This will not affect your studies but is a way of the University tracking.
Yes
No
How would you like Project LUNA to follow up with you?
email
phone
Best days/times to reach you (e.g., “Weekdays after 5 PM,” “Anytime weekends”):
Would you like support going to the police?
Yes
No
Already done it
Would like Advice
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Your Information
We collect diversity information to help us build anonymous reports and better understand patterns and trends in incidents. This data helps us track occurrences and ensure we are addressing them effectively.All information is stored securely and anonymously. We will retain this data for a defined period, in accordance with our data protection policies.
Do you give us permission to store this information?
Yes
No
Age
Sexuality
Gender
Do you believe yourself to be disabled or neurodivergent. If yes: please state.
You do not need to be diagnosed for this section as we understand how hard it can be to be diagnosed.
Nationality
Race
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Confidentiality & Consent
Confidentiality Notice:
All information provided will be handled with strict confidentiality. Project LUNA will not publicly disclose identifying details without your explicit permission. If you choose to remain anonymous, no one will be able to trace this report back to you.
Consent to Use Information:
By submitting this form, I confirm that the information provided is as accurate as I can make it. I understand that Project LUNA may use non-identifying details from this report to compile statistics, advocate for safer spaces, or inform policy recommendations.
I consent to this use of my information
I do not consent to use my information for anything beyond direct follow-up in this case.
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Thank you for reporting.
For any questions about this form or for further support, email support@projectluna.orgWe appreciate your courage and trust in Project LUNA.
Support
If you need support with what has happened, check out our support section of the website.
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