Report an incident

Your email address(Required)

1. Type of incident?(Required)

Smear campaign against a particular Muslim individual or an Islamic organisation/entity

Meme

Politicians’ statements (and their circulation)

Petition campaign

Organised action (boycotting, rallies… )

Interpersonal harassment and intimidation

Comment on a social media post

Other (please specify)

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2. Online platform(Required)

FB, FB Messenger

Instagram

Youtube

Website/Blog

Unknown

Other (please specify)

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3. Date of the incident(Required)

DD slash MM slash YYYY

4. Social media account name of perpetrator(Required)

5. Provide the screenshot or link about the reported incident (choose one)(Required)

I have a screenshot

I have a link

Provide the screenshot about the reported incident

Drop files here or

Max. file size: 456 MB.

Link to incident

6. Can you tell us about the incident? Please give details of what, where, when, it happened and what the perpetrator said and did?

Type or upload an audio recording (using voice recorder)

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

Max. file size: 456 MB.

7. Any other supporting documents

Drop files here or

Max. file size: 456 MB.

8. Have you reported to:

Police

Anti-Discrimination Board

Human Rights Commission

Other (please specify)

Police report no. or other (please specify)

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

Yes

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

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

Witness

Victim

Victim’s friend/relative/proxy

13. Victim’s gender?

Not applicable (if it is generically targeting all Muslims)

Male

Female

14. Victim’s age group?(Required)

Not applicable/Unknown

0-9

10-20

21-30

31-40

41-50

51-60

60 or above

15. Victim’s ethnic origin?(Required)

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)

Post Custom Field

16. Perpetrator’s gender?(Required)

Male

Female

Unknown

Multiple perpetrators (please specify)

Post Custom Field

17. Perpetrator’s age?(Required)

Unknown

Multiple perpetrators

0-9

10-20

21-30

31-40

41-50

51-60

60 or above

Post Custom Field

18. Perpetrator’s perceived ethnicity?

Anglo

Non-Anglo

Unknown

Multiple perpetrators

Post Custom Field

Your details

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

Name(Required)

First Last

Phone

State(Required)

Postcode(Required)

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

Reporting only

Advice/advocacy assistance

Referral (counselling, legal support, social services etc)

Hidden

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

ExcellentPretty goodNeutralNot so greatTerrible

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

ExcellentPretty goodNeutralNot so greatTerrible

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