BV RESPONSE TO RACISM AND HATE REPORT FORM

BV RESPONSE TO RACISM AND HATE REPORT FORM
Purpose and guidelines for completing this form

Use this form or our online portal to report an incident of racism, hate or discrimination.
• The documentation of incidents is to

1) support victims,

2) better understand the nature and extent of discrimination in the valley, and

3) provide community engagement and education opportunities.

• The Smithers Bridging Committee will not be investigating incidents. Reports can be made by individuals, governments, organizations, and businesses.

• Reports will be held in confidence and are anonymous unless the victim provides their information for support, or for assistance with making a report to the police or other relevant agency.

• The Smithers Bridging Committee will not keep any personal information of individuals other than the victim (if the victim provides consent).

• Reports that meet the criteria of an alleged “Hate Crime” may be referred to the RCMP where they will be subject to their privacy and confidentiality policies.

• Anyone providing information using this form must do so with informed consent, which can be given in the last few questions in this form.

• If preferred, you can print the reporting/documentation form and email it to reports@smithersbridgingcommittee.ca or give it to a member of the Bridging Committee.
Your relationship to the incident?

VictimBystanderWitnessProperty OwnerSupporting OrganizationYou are representing the victim to report the incident, and your relationship to the victim is _________ (Eg: parent, friend, teacher).Other
Clarifying information (if needed):
Apparent nature of incident?

Race/Ethnicity basedSexual Orientation basedGender basedBelief/Faith basedSpecial Needs/Abilities basedAge basedOther
Clarifying information (if needed):
Date of the incident:

MonthDayYear
Date
Time of day of the incident?
Location of the incident?

Private business (restaurant, store, spa, auto services, etc).Government building (Town Hall, Court House, government services).Healthcare facility (Hospital, long term care home, medical/dental clinic).Place of worshipPublic space (sidewalk, park, library, pool, recreational site).School (Elementary, Secondary, College).ONLINE Forum (social media, email).Other
Location further details. Eg: address, and or name of location, "other" info, etc.
Witnesses?

YesNo
If Yes, number of witnesses:
Details of the incident - describe what took place, the number and details of the people involved:
Explain what attempts, if any, have been made to address the incident; and after the incident what happened to the victim, and to the perpetrator? Have organizations, such as the RCMP, store management, school staff, been made aware of it?
Informed Consent
I consent for this form to be stored by the Smithers Bridging Committee.

YesNo
I understand that a shorter incident report form will be filled out with the removal of any information that may identify myself or others, to ensure confidentiality and anonymity.

YesNo
If I have provided contact details, I understand no further steps will be taken to share this information without my prior and informed consent.

YesNo
If this incident is being reported by a second or third party, confirm if the person who experienced the incident has been informed of it being reported and has given consent.

YesNo
*If no, they should be informed. **If consent cannot be received, the report will be revised to ensure anonymity.
Final Comments
Anything else you wish to add:
Contact
I would like to be contacted by the Smithers Bridging Committee for follow-up:

YesNo
If Yes, contact info:
Today's Date

MonthDayYear
Should be Empty:

BV RESPONSE TO RACISM AND HATE REPORT FORM

Purpose and guidelines for completing this form

Informed Consent

Final Comments

Contact