All
information you provide will be kept strictly confidential. The executive
director of Council of Agencies Serving South Asians (CASSA) may contact
you for further inquiry into your incident.
"Please fill this form only if you experienced a hate crime in Canada
specifically in the Greater Toronto Area and surroundings."
1. Personal Information
SELF
ON
BEHALF OF SOMEONE ELSE
CULTURAL
INTERPRETER
First Name
Last Name
Street Address
City
Province
Postal Code
Country
Canada
Phone
E-mail
2. Facts of the Incident
Date/Time of Incident:
Location of Incident:
Description of Suspect(s):
Description of Weapon(s):
Description of Travel of
Suspect(s):
Were you verbally abused
during the incident?
Yes
No
What did the suspect(s) say?
Were you harassed or
discriminated? Tell us How/Why?
Description of Incident:
If you were injured, describe
the injuries:
Was anything stolen? Please
describe:
3. Incident Category
Arson
Hate
Propaganda:
Assault
(physical)
Assault
(sexual)
Stalking
Attempted
Murder
Threats
Break
& Enter
Robbery
Graffiti
Vandalism
Harassment
Other
4. Check Mark Location of
Incident
Community
Centre
Bar/Club
Government
Building
Home
Housing
(Public)
Sporting
Library
Theatre
Parks &
Recreation
Place
of Worship
School/University/College
Private
Institution
Street
Shopping
Mall/Centre
Transit
Other
5. Victim's Identity
Would you know the person's
religion/gender/race/ethnicity/nationality?
