Friday, April 14, 2006

Racist Incident Reporting Form Page 1

What follows is a copy of the form being handed out around Queensland. Victor apologises for any errors but it was not a perfect OCR scan. Anyway you can get the idea of what it is all about.

Date:

Worker

Organisation:

This Racist Incident Reporting Form was developed by the Centre for Multicultural Pastoral Care as part of the Confronting Racism in Communities Project.

The Confronting Racism in Communities Project aims to work with communities to document the nature and extent of racism in Queensland and provide communities with support, training and resources In order to combat racism.

This form is designed to be completed by people who have experienced racism (with the assistance of trained community workers) or by workers themselves when the people who have experienced racism are not available to teal their story.

All information will be kept in the strictest confidence and no identifying information will be forwarded to a third party without consent.

Completing this form will help us to understand the nature and extent of racism In Queensland. It will not mean that you have lodged a formal complaint. Complaints can be directed to some of the agencic2s listed on the final page of this form. Thank you for sharing your experiences with us.

1] Person who experienced racism;

1. Name (optional) —
2. Address (optional)
3. Telephone number (optional) _____
4. Email address (optional) _________
5. Country of origin and/or ethnic background
6. Length of time in Australia

0-12 months More than 10 years
0 1-5 years 0 Born in Australia
06-10 years 0 Unknown

7. Male Female

8. Age

Younger than 10 years 0 40-49 years
10-19 years 0 50-59 years
020-29 years 0 Older than 59 years
30-39 years (El Unknown

9. Religion

Christianity
Buddhism
Islam
Judaism
Hinduism
None
Sikhism
Unknown

Other (please specify) ____

10. Language spoken at home

11. Level of spoken English

Very good
Good
Fair
Poor
Very Poor

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