Racism Report form (E)

Racist discrimination in the region of Basel

Discrimination and violence exist in many forms and there are different ways
to take action against them!
This form offers you the possibility to report discrimination and to receive professional
advice from the office «Stopp Rassismus» (stop racism). If you do not wish to receive counselling, your report will be forwarded to the office «Stopp Rassismus» so that it appears in the statistics.

Tick the appropriate boxes:

I’d like to
report an incidentreport an incident and receive advice

I was
directly affected by the incidentwitnessing the incident

When? Date, ev. time of incident:

Where?
institution (e.g. shop, bank)public space (e.g. at park)administration (e.g. tax offices)job search, job marketschool, work placeapartment search, tenancyprivatepolice

What?
discrimination, disadvantagemobbingphysical attackproperty damageinsultsfalse accusationrefusal of services

short description of the incident:

First name:

Family name:

Phone:

e-Mail:

Place:

Date:

Privacy policy:
I accept the data privacy statement

Your info is treated confidentially.

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