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Racist Incidents Report Form
Please E Mail this form to:nccri@eircom.net Or post to:
Director 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  Main Page |
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