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Hate Incident Report Form

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.




1. BASIS FOR THE HATE INCIDENT

A hate incident is a non criminal act targeting a particular group. Based on your impressions, why was (were) the victim(s) targeted?

Age
Social condition
Political beliefs
Marital status
Pregnancy
Disability
Language
Sexual orientation
Race or colour
Religion
Sex
Ethnic or national origin

Details regarding basis for incident :




2. VICTIM, WITNESS OR THIRD PARTY

Have you been the victim of hate incident ?

Yes
No

Have you witnessed a hate incident without being one of its victims?

Yes
No

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".

Third party




3. INFORMATION ON THE VICTIM

Victim's name

Sex

Male
Female
Other
I prefer not to answer

if other

Year of birth

Occupation

Adress

Postal code

Telephone number (home and work)

Telephone number (cell)

E-mail

In your opinion, does the victim belong or identify as belonging to a visible minority/ethnic group?

Black
East or South-East Asian
South Asian
Arab or West Asian
Latin Americain
Indigenous
White
Mulitple visible minorities
Unknown ethnic group




4. DETAILS REGARDING THE HATE INCIDENT

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?

Yes
No
I don't know

Was any property lost or damaged?

Yes
No
I don't know

What happened?
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?

Yes
No
I don't know

Notes: (Comments regarding any witnesses)




5. INFORMATION ABOUT THE PERPETRATOR OF THE HATE INCIDENT

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?




6. CONTACTING YOU

Would it be possible to leave you a voice message if a CPRLV worker wishes to reach you?

Yes
No

Would it be possible to leave you a voice message if a CPRLV worker wishes to reach you?

Yes
No

Would you like to meet with a member of the Centre's staff to discuss the incident?

Yes
No




7. Would you like to receive specialized support from the Center? If so, please specify

Yes
No

Specify:



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.