Racial and Other Profiling Questionnaire
Interviewer: ___________________________________________________________________
Date/Time/Location of interview: __________________________________________________
Interview
We are collecting information on racial and other profiling in an effort to better understand
problems that exist, track the problems, and potentially work to help those undergoing this form of
discrimination.
Criminal profiles are a set of personal and behavioral characteristics associated with particular
offenses that police use to predict who may commit crimes in the future, or identify what type of
person may have committed a particular crime for which no credible suspect has been identified
or eye-witness description provided. Criminal profiling becomes racial or other discriminatory
profiling when these characteristics include race, ethnicity, nationality, religion or sexual
orientation.
This interview is intended to address a variety of potential police encounters, or encounters with
security personnel of private businesses, that may have been a result of racial or other profiling.
If you are asked a question that does not apply to you and your story, please feel free to say so.
For those questions that do apply, it is very important that you be as detailed and specific as
possible in your responses.
The information you provide will be kept confidential unless you specify otherwise.
Name: _______________________________________________________________________
Age: _____ Sex: _____ Race or national origin: _____________________________________
Address: _____________________________________________________________________
Phone number: ________________________ Email: _________________________________
Current employment if any: _______________________________________________________
Primary language: ______________________ Do you need an interpreter? Yes ___ No ____
Which of the following best describes the reason you have agreed to be interviewed?
1. _____ I was a driver who was pulled over.
2. _____ I was a passenger in a vehicle that was pulled over.
3. _____ I was approached by police or security personnel for something other than a traffic
stop.
4. _____ I am a professional or other advocate for a victim or complainant.
Do you believe you were the victim or target of discriminatory profiling? Yes ___ No _____
Did the officer say or do anything to you that made you believe race (or other basis of
discrimination) played a factor? Yes _____ No _____
If yes, please explain:____________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
What type of profiling was it?
1. _____ Racial
2. _____ I am Hispanic
3. _____ I am Muslim
4. _____ I am Lesbian, Gay, Bisexual, Transgender
5. _____ I am a foreigner
6. _____ I am a member of a political group
7. _____ Other: _______________________________________________________________
If you know, what was the name and badge number of the officer who stopped you?
Name: ___________________________________________ Badge #: __________________
What law enforcement agency did the officer work for?
1. _____ Local police: _______________________________________________________
2. _____ County sheriff: ______________________________________________________
3. _____ Iowa State Patrol
4. _____ ATF (Federal Alcohol and Firearms)
5. _____ DEA (Federal Drug Enforcement)
6. _____ ICE (Immigration)
7. _____ TSA (Transportation Security)
8. _____ Private business security
2 9. _____ Other: ____________________________________________________
10. _____ Unknown
Please provide the following information about the encounter:
1. City where the incident occurred: ________________________________________________
2. Location (street/intersection): __________________________________________________
3. Date: ____________________________________ 4. Time of day: ___________________
Please describe what happened with as much detail as possible:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Were you given a reason for the stop or encounter? Yes _____ No _____
If yes, what was the reason?______________________________________________________
____________________________________________________________________________
_____________________________________________________________________________
Was anything else said to you? _________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
What happened that made you think you were being profiled?________________________
_____________________________________________________________________________
_____________________________________________________________________________
Were you ever told you were free to leave? Yes _____ No _____
If yes, when were you told you were free to leave? ____________________________________
____________________________________________________________________________
3 If this was a traffic stop, were you asked to provide your driver's license, registration and
proof of insurance? Yes _____ No _____
If this was not a traffic stop, were you asked to provide identification? Yes ____ No _____
Were you asked to provide any other documents? Yes _____ No _____
If yes, what documents? _________________________________________________________
Were you searched, or, if this was a traffic stop, was the vehicle you were in searched?
1. _____ Yes, me
2. _____ Yes, car
3. _____ Yes, both
4. _____ Neither
If you were searched, did the officer advise you that you had a right not to allow the
search? Yes _____ No _____
If you were searched, did the officer ask permission to search you?
Yes _____ No _____ If yes, how many times were you asked to be searched? _____________
If you were searched, what if anything was found? _________________________________
_____________________________________________________________________________
If your car was searched, did the officer ask permission to search it? Yes _____ No _____
If your car was searched, what if anything was found? ______________________________
_____________________________________________________________________________
During the course of the police encounter, did any of the following occur?
1. Given a verbal warning
Yes _____ No _____
2. Given a ticket or citation
Yes _____ No _____
3. Handcuffed
Yes _____ No _____
4. Given Miranda warning
Yes _____ No _____
5. Assaulted
Yes _____ No _____
6. Property seized
Yes _____ No _____
7. If yes to any of these things, for what offense(s) were you warned / ticketed / arrested?
_____________________________________________________________________________
4 As a result of the police stop / encounter, did any of the following occur?
1. Taken into custody
Yes _____ No _____
2. Court proceedings
Yes _____ No _____
3. Immigration Proceedings Yes _____ No _____
4. Probation Revocation
Yes _____ No _____
5. Parole Revocation
Yes _____ No _____
Were there any others with you when you were stopped or approached by the police?
Yes _____ No _____
If yes, how many _____, and what is / are their races? _______________________________
If yes, were they also questioned? Yes _____ No _____
If yes, were they also searched?
Yes _____ No _____
May we contact them? Yes _____ No _____
If yes, how can we contact them? _______________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Were there any other witnesses to the stop? Yes _____ No _____
If yes, may we contact them? Yes _____ No _____
If yes, please provide their contact information:
_____________________________________________________________________________
_____________________________________________________________________________
How long did the entire traffic stop or encounter take?______________________________
____________________________________________________________________________
In addition to the profiling incident you have described, have you been the victim of any
other incidents that you believe were caused by discriminatory profiling?
Yes _____ No _____ If yes, how many? _____
Approximately how many times have you been stopped by law enforcement or private
security personnel in the last year?____________________________________________
5 Did you make a complaint to any agency or organization about this stop or search?
Yes _____ No _____
If yes, to whom did you make a complaint? ________________________________________
What, if anything, was the response? ____________________________________________
List anyone who is helping you respond to the incident:
_____________________________________________________________________________
_____________________________________________________________________________
As a result of this incident, are you doing anything differently now when traveling?
Yes _____ No _____ If yes, please explain_________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
May we digitally record an interview with you? Yes _____ No _____
Are you willing to be contacted by the press or others? Yes _____ No _____
If you are hesitant for us to make your story public, are you willing to allow us to share
your story without identifying you? Yes _____ No _____
In addition to gathering individual stories of profiling incidents, we are also gathering data
that will help determine the extent of profiling in our community. If you do not want us to
share the details of your incident publicly, may we use the details for statistical
purposes? Yes _____ No _____
Thank you for taking the time to answer these questions. We will use your responses to the
extent you have given us permission.
Please understand that we are not offering legal advice or representation. If you wish to pursue
legal action you should consult with a private attorney.
Do you have any other questions?
Thank you again for sharing your story with us.
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