Report for Myself

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519-722-2449 report@cmw-kw.org Emergency: Call 911 Coalition of Muslim Women of K-W

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Incident Classification

Hate Crime Incident Classification Hate-Motivated Crime Incident Classification Hate Incident Incident Classification Online Hate Incident Classification Discrimination Incident Classification Other (please specify) Incident Classification

Incident Sector

Education Incident Sector Housing / Neighbourhood Incident Sector Healthcare Incident Sector Employment Incident Sector Online Incident Sector Public Services Incident Sector Police Services Incident Sector Businesses Incident Sector Place of Worship Incident Sector Public Spaces Incident Sector Public Transit Incident Sector

* Date of Incident If you don't remember the exact date, please provide the closest approximate date.

Ethnicity

Black Ethnicity East or South-East Asian Ethnicity South Asian Ethnicity Arab or West Asian Ethnicity Indigenous Ethnicity White Ethnicity Other Race or Ethnicity Ethnicity Race or Ethnicity Not Specified Ethnicity

What kind of support was provided?

Work with Law Enforcement Agencies What kind of support was provided? Work with Human Rights Tribunal What kind of support was provided? Work with Regulatory Body What kind of support was provided? Work with a Lawyer What kind of support was provided? Work with Service Provider What kind of support was provided? Work with School / School Board What kind of support was provided? Liaising with Law Enforcement What kind of support was provided? Liaising with service provider What kind of support was provided? Work with Post-Secondary Education What kind of support was provided? Emotional support/system navigation What kind of support was provided? Counselling What kind of support was provided? Advocacy What kind of support was provided? Mediation/Sulah What kind of support was provided? Referral What kind of support was provided? Other What kind of support was provided?

Other support If you answered "Other" above, please specify.

Notes Last updated notes should be at the top

Case Status Open Closed

* I am

Incident Location

* City / Municipality

Other City / Municipality If you answered "Other" above, please specify.

* Province

If possible, please provide an address or nearby landmark where the incident occurred

* Where did the hate act take place? Workplace Public School / Private School College / University Hospital / Healthcare Clinic / Physiotherapist / Mental Health Clinic / Dentist / etc. With Police / RCMP / OPP / etc. Government Office / Services (e.g. Service Ontario / Passport Office / City Hall / Court / Children's Aid / FACS / Animal Welfare / etc.) With Municipal / By Law officer Public Transit Park / Street / Parking Lot Community Centre / Library / Museum / etc. Private Residence Religious Property Shopping Mall / Grocery Store / Retail Store Private Business (Gyms / Theatre / Restaurant / Waterparks / etc.) With Landlord / In Neighbourhood Social Media Post / Private Online Group / Private Message Prefer Not To Say Other

Other If you answered "Other" above, please specify the place.

Incident Details

* What happened during the incident? Verbal Hate / Harassment (Name Calling / Offensive Jokes, Racial Slurs / etc.) Publicly Spreading Hate Against a Group (e.g. Inciting Genocide / Antisemitism / Islamophobia / Racism/ etc.) Bullying / Intimidation (Continuous Harassment Such as: Spreading Rumours / Excluding People from a Group / Emotional Harm / etc.) Threats of Violence Physical Assault (Including with a Weapon / Spitting / Pulling Off Hijab / etc.) Vandalism (Graffiti / Destruction / Damage / Harm to Property or Personal Belongings) Online Abuse (Email / Social Media) Hoax Calls / Abusive Phone or Text Message / Hate Mail Discrimination / Unfair Treatment (by Landlord / Doctor / Employer / Teacher / Police Officer or Another Service Provider) Displaying or Spreading Hateful Symbols/ Images / Posters / Literature Threatened by Dogs Prefer Not to Say Other

Other incident If you answered "Other" above, please specify.

* In your opinion, what is the reason for this incident?

Select all that apply

Racism In your opinion, what is the reason for this incident? Islamophobia In your opinion, what is the reason for this incident? Anti-Immigrant Hate (xenophobia) In your opinion, what is the reason for this incident? Anti-Asian Racism In your opinion, what is the reason for this incident? Anti-Black Racism In your opinion, what is the reason for this incident? Anti-Indigenous Racism In your opinion, what is the reason for this incident? Antisemitism In your opinion, what is the reason for this incident? Prefer Not To Say In your opinion, what is the reason for this incident? Other In your opinion, what is the reason for this incident?

Other reason If you answered "Other" above, please specify.

Tell us what happened in as much detail as possible You can attach evidence below

Evidence Please attach any relevant photos, video, or documents that may be relevant to the incident.

Supported file types: Word, PDF, GIF, JPG, PNG, HEIC, WEBP, MP4, M4V, AVI, MOV

If evidence files exceeds 10MB, please email report@cmw-kw.org to arrange for further support.

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What is the victim's age group? 18 and Under 18 - 24 25 - 30 31 - 40 41 - 50 51 - 60 61 - 70 70 and Older Doesn't Apply (Group or Community was Targeted) Prefer not to say

What is the victim's gender? Male / Male-Identified Female / Female-Identified Other (Please specify) Prefer Not to Say Doesn't Apply (Group or Community was Targeted)

Other gender If you answered "Other" above, please specify.

What is the victim's ethnicity?

Select all that apply

Arab What is the victim's ethnicity? African What is the victim's ethnicity? Bi-Racial What is the victim's ethnicity? Black What is the victim's ethnicity? East or South-East Asian (Chinese / Korean / Vietnamese / Indonesian / etc.) What is the victim's ethnicity? South Asian (Indian / Pakistani / Sri Lankan / Nepalese / Bangladeshi etc.) What is the victim's ethnicity? West Asian (Turkey / Afghanistan / Iran / etc.) What is the victim's ethnicity? Indigenous Peoples What is the victim's ethnicity? Central or South Americans What is the victim's ethnicity? White (European / Caucasian / etc.) What is the victim's ethnicity? Prefer not to say What is the victim's ethnicity? Other (Please specify) What is the victim's ethnicity? Doesn't Apply (group or community was targeted) What is the victim's ethnicity?

Other ethnicity If you answered "Other" above, please specify.

What is the victim's religious / faith background? No Religion Buddhist Christian Hindu Jewish Muslim Sikh Indigenous Spirituality Prefer Not to Say or Doesn't Apply Other (Please specify)

Other religious / faith background If you answered "Other" above, please specifiy.

Was the victim wearing any cultural / religious clothing when the incident took place? No Cross Hijab / Head Covering Kippa Turban Other

Other clothing If you answered "Other" above, please specify.

* Do you want help from CMW? Yes No

Personal Information

These fields are optional if you do not require help. If you wish, you can submit the report anonymously.

First Name

Last Name

Phone Number

Email

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