National Consultative Committee on Racism and Interculturalism
Racist Incidents Report Form

Please E Mail this form to:nccri@eircom.net

Or post to:

Director
NCCRI,
26 Harcourt Street,
Dublin 2.
Fax 01 4785777

Reporting Organisation Information

Organisation:

_______________________________________________

Name of the person filling in the form:

_____________________________________

Date: __________________________________

Victim Information

Please do not include information that would identify the victim e.g. address, name.

Place of residence: City: __________ County: __________

Age: ___________ years

Occupation: ____________________

Gender: Male ___ Female ___

Nationality: __________

Legal Status: _________

Ethnicity: More than one box can be ticked

Black ___

White ___

Traveller ___

Indian ___

Chinese ___

Other (please specify) ____________________

Information on the incident

 

Please include all relevant information.

 

Date and Time of incident:

_____________________________________

Location of incident: ____________________________

____________________________________________

What happened?

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

Have you reported the incident to the Gardai? Yes ___ No ___

Have you reported the incident to another authority? Yes ___ No ___

If yes, which one? _______________________________________________

Which further action is/was envisaged or taken? _________________________________________________

_________________________________________________

_________________________________________________

________________________________________________

_________________________________________________



Character of the incident

Please tick

Access to public places/shops

 

Accommodation

 

Attacks/Physical abuse

 

Education

 

Entertainment sector/pubs

 

Government agencies

 

Health sector

 

Hostility at place of residence

 

Job market

 

Legal

 

Media portrayal

 

People wearing offensive badges, insignia or tattoos

 

Policing issues

 

Racist comments or other cultural disrespect

 

Racist graffiti

 

Racist jokes

 

Social and personal contact

 

Transport

 

Verbal abuse/Name-calling

 

Workplace

 

Other

 

Please return to the address given at the top of the form

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