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? _________________________________________________

_________________________________________________

_________________________________________________

________________________________________________

_________________________________________________

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

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