1. What happened (short description of the incident)?
2. When occurred the discrimination (date, time…)?
3. Where took the discrimination place (town)?
4. Due to which characteristics or categorisations happened the discrimination (personal assumption)?
ethnic affiliation/ origin
race/ skin colour
gender identity
sexual identity/ orientation
disability
age
class/ social affiliation
Other
5. Where took the discrimination place?
employment market (job, application, training...)
education (school, university…)
public authorities (e.g. job center, foreigners' office, youth welfare...)
sports/ leisure
restaurant/ club etc.
health care
public transport
police
housing market (apartment, lease...)
social services (e.g. child care, elderly care, social counselling...)
insurances
Other
6. What kind of discrimination did you experience?
insult
threat
unequal treatment in services: (e.g. no admittance to clubs, higher prices/ fees, denial of selling/ contract)
physical violence
sexual harassment
damage of property
Other
7. Personal informations
Gender of the person affected by discrimination:
Contact informations (only necessary if you wish counselling):
Name, e-mail address or telephone number
I would like to report the case anonymously
Send
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