Friday, April 14, 2006

Racist Incident Reporting Form Page 2

12. Level of written English

[] Very good [] poor [] Good [] Very poor [] Fair

13. Is the person who experienced racism the person completing this form?

[] yes

About the racist incident

14. Would you like to report a single incident or multiple incidents? [] Single incident [] Multiple incidents (go to question 16)

[] Incident(s)

If no, who is completing this form? (Please specify xr name and/or relationship to the person who experienced racism)

15. Date of racist Incident (dd/mm/yyyy)

16. How frequent were the racist incidents? ______ incidents per week/month/year for the past
(go to question 17) weeks/months/years (please circle)

17. How would you describe the incident(s)’


[] Physical violence [] Threat of physical violence [] Property damage
[] Threat of property damage []Racist graffiti [] Offensive media content
[] Discrimination [] Other (please specify) Verbal harassment (eg. offensive joke or comment) []Non-verbal harassment (eg. offensive look or gesture) Physical harassment (eg. unwelcome physical contact) [] Written harassment (eg. offensive letter or email) [] Display of offensive materials (eg. posters or t-shirts) [] Social exclusion (eg. someone ignored you or avoided you)

18. In which town/suburb and postcode did the Incident(s) take place?

19. In which location(s) did the incident(s) take place?

[]At home fl In a sportsground, picnic area or other place of leisure
[]At work D At a mosque, synagogue or other place of worship
[] At school, technical college or university [] In a letter, phone-call, text-message, fax or email
[] In a supermarket or [] In a newspaper, magazine or website or on television or radio
[] In a café, restaurant, pub or nightclub [] While applying for a job or course
[] On the street [] While applying for rental accommodation
[] While travelling on public transport [] While accessing government/community services
[] While travelling in a private vehicle
[] Other (please specify) ____________

20. Please provide a brief description of the racist incident(s). (You may

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