Please fill out this confidential form if you have been the victim of or witness to a hate incident. You may also use this form to report an incident on the victim's behalf.
A hate incident is a non criminal act targeting a particular group. Based on your impressions, why was (were) the victim(s) targeted?
Details regarding basis for incident :
Have you been the victim of hate incident ?
Have you witnessed a hate incident without being one of its victims?
If you are reporting a hate incident on behalf of a victim, without having been a victim of or witnessed the incident yourself, please check "third party".
Year of birth
Telephone number (home and work)
Telephone number (cell)
In your opinion, does the victim belong or identify as belonging to a visible minority/ethnic group?
Time and Date of Hate Incident
Place and Context of Hate Incident (e.g.: in the street, at school, in public transit, specific street and neighborhood, etc.)
Was anyone injured in the hate incident?
Was any property lost or damaged?
Please include as much information as possible. State precisely what about the incident makes you feel it was motivated by hatred (e.g.: things said, the nature of the incident).
Did anyone witness the hate incident?
Notes: (Comments regarding any witnesses)
At the time of the hate incident, how many perpetrators were you able to identify as being involved?
Did you know or had you previously crossed paths with the perpetrator(s) of the hate incident?
Would it be possible to leave you a voice message if a CPRLV worker wishes to reach you?
Would you like to meet with a member of the Centre's staff to discuss the incident?
We strive to offer you a service that is best suited to your situation. Unless you advise us otherwise, we assume you agree that the information pertaining to your request for service be shared between our professionals and this, in accordance with the rules of confidentiality.