Report for Someone Else

Comox Valley anti-racism and anti-hate incident reporting form

Thank you for being here. The information you provide here is held confidentially by the Community Justice Centre. If you have any questions please call 250-334-8101 and ask to speak to the Managing Director or email manager@communityjusticecentre.ca
Our work occurs through a restorative justice lens, which includes ongoing voluntary consent with those impacted. We prioritize the safety of those affected. This service and form is not intended to replace emergency services. If you are in immediate crisis or danger, call 911.
Anonymized data collected from this form will be used to track patterns of racism and hate in our community. (Please contact the CJC if you have any questions.)
Are you reporting as a:

Other
If other please explain:
What is your age range?
What is your gender identification? (you can choose all that apply
None of the following fields are mandatory. However if you would like to explore support resources or a response through a restorative justice lens, please provide your contact information.
Date of incident(s)
Approximations are okay. Incidents do not have to be current.
Please describe what happened
If possible and relevant, include information on who was involved and where it occurred. If you'd rather provide this information verbally, please indicate that here. if you don't know all the info that is okay too.
If relevant, has this incident been reported to the RCMP?
How would you describe yourself in relation to this incident/incidents?
If you answered "Other" above, please describe:
Which region did this incident occur in?
Where did the incident occur?

Other
Other/ more location details
Details of the specific location or other location information, if applicable.
How would you classify the incident? (You can select more than one option.)

Other
Please upload any relevant photos or information you would like to include:

Cancelof
In your opinion, what was the reason for the incident? Please select all that apply. (This non-exhaustive list helps us to track patterns of harm in our community.)

Other
Is there anything else you would like to add?
What happens next?
If necessary, may we contact you for the sole purpose of clarifying the information you provided about the incident?
Would you like someone to contact you to discuss and explore possible options for support and/or a restorative justice response?
The following information is only required if you answered yes to either of the above questions.
Your name
Preferred Name
Your email address
Please enter your email address if you'd like to hear from us via email in reference to this incident (the CJC will never contact you in any other capacity unless you give your express permission).
Pronouns
Your phone number
Please enter your phone number if you'd like to receive a call from us.Format: (000) 000-0000.
I prefer to be contacted by:

Other
Is there anything else we need to know about contacting you?
E.g. best time(s) to call, letting us know NOT to leave a message.
Would translation services, assist you, if so please let us know which language?
We aim to respond within seven days, but it may take longer.
You may also choose to report by calling the BC United Way Racist Incident Helpline (https://racistincidenthelpline.ca) at 1-833-457-5463. Someone is available to speak to you there, Monday through Friday, from 9:00 a.m. to 5:00 p.m., in over 240 languages. If you ask them, they will share the information with the Community Justice Centre.
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Comox Valley anti-racism and anti-hate incident reporting form

Our work occurs through a restorative justice lens, which includes ongoing voluntary consent with those impacted. We prioritize the safety of those affected. This service and form is not intended to replace emergency services. If you are in immediate crisis or danger, call 911.

What happens next?

The following information is only required if you answered yes to either of the above questions.