Report an incident

1. Type of incident?(Required)

Hate Speech/Verbal Threat

Non-Verbal Intimidation

Graffiti/Vandalism

Physical Assault

Discrimination at workplace/school or by authorities

Written Materials

TV, Radio and Print Media

Other (please specify)

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2. Who is filling out this form?(Required)

Victim

Victim’s friend/relative/proxy

Witness/bystander

3. Victim’s gender?(Required)

Male

Female

Rather not say

Not applicable

4. Victim’s age group?(Required)

Not applicable

0-9

10-20

21-30

31-40

41-50

51-60

60 or above

5. Victim’s ethnic origin?

Not applicable

Arab

Afghan

Indian/Bangladeshi/Pakistani

White/European/Anglo

African

From Asia-Pacific

From Balkans & Near East (e.g. Turkey) or Cypriot

Other (please specify)

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6. Was the victim wearing any religious clothing or other religious markers (eg. a beard) at the time of the incident?

Yes

Not applicable

If you answered yes to the above, please detail what the victim was wearing.

Hijab (headscarf)

Face-veil

Beard

Skull-cap

Long robe

Other

7. Perpetrator’s gender?(Required)

Male

Female

Unknown (in cases of graffiti/vandalism)

8. Perpetrator’s age?(Required)

Unknown

0-9

10-20

21-30

31-40

41-50

51-60

60 or above

9. Perpetrator’s perceived ethnicity?(Required)

Anglo

Non-Anglo

Unknown

10. Date of the incident(Required)

DD slash MM slash YYYY

11. Postcode, State(Required)

12. Can you tell us about the incident? Please give details of what, where, when, it happened and what the perpetrator said and did? (Type below or upload an audio recording)(Required)

Upload audio recording here (use voice recorder on your phone and use this field to upload)

Max. file size: 256 MB.

13. Any other supporting documents

Drop files here or

Max. file size: 256 MB.

14. If you feel like you were affected by the incident, please select which emotions you felt?

Sadness/worry (unhappy, upset, concerned, nervous)

Anger (annoyance, fury, irritation, frustration, disgust, rage, Sickened etc.)

Fear/being scared (panicking, feeling unsafe/insecure)

Humiliation (shame and embarrassment)

Disappointment (despair, helpless, surprised/shocked)

Other (please specify)

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15. Can you tell us if the incident left any long-term impact? If so, what type of impact?

16. Have you reported to:

Police

Anti-Discrimination Board

Human Rights Commission

Other (please specify)

None

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This helps us to understand the variety of reasons why people may not report to the appropriate body.

17. Do you want the Register to forward your report to the Police?

Yes

Your details

Required for verification & advocacy purposes. Your details are strictly confidential.

Name(Required)

First Last

Email(Required)

Phone

Please provide your phone number should you require follow-up support.

How can we help you? (please select one of the following)

Reporting only

Advice/advocacy assistance

Referral (counselling, legal support, social services etc)

How did you find this reporting experience? (not satisfied - very satisfied)

ExcellentPretty goodNeutralNot so greatTerrible

Optional feedback

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This field is for validation purposes and should be left unchanged.

I’d like to report an incident in real life

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