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.)
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Yes, I consent to the anonymized use of the data I submit in this form.
Are you reporting as a:
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Directly affected individual
On behalf of someone else
As a bystander
Other
If other please explain:
What is your age range?
0-18
19-30
31-40
41-50
51-60
61-70
71+
What is your gender identification? (you can choose all that apply
Female
Male
Non-binary
Gender queer
Transgender
Prefer not to say
Other
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?
Yes
No
Not applicable
Unsure if it is applicable
How would you describe yourself in relation to this incident/incidents?
Please Select
The directly affected individual
A witness
Reporting on behalf of someone
A member of the affected community
Other
If you answered "Other" above, please describe:
Which region did this incident occur in?
Please Select
Black Creek
Comox
Courtenay
Cumberland
Denman Island
Fanny Bay
Hornby Island
Merville
Mount Washington
Online
Royston
Union Bay
Where did the incident occur?
Workplace
Elementary school
High school
College / trades school
Medical setting
Public transit
Park / street / parking lot
Public facility (eg: community centre, library, museum)
Private residence
Private business
Community service
Formal or informal encampment
With landlord
Social media post / private online group / private message
Law / bylaw enforcement / security
Prefer not to say
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.)
Verbal hate / harassment (name calling, offensive jokes, racial slurs, etc.)
Publicly spreading hate against a group (e.g. antisemitism, islamophobia, racism, homophobia, transphobia, etc.)
Bullying / intimidation (conscious harassment such as: spreading rumours, excluding people from a group, emotional harm, etc.)
Threats of violence
Physical assault (including with a weapon, spitting, pulling off hijab, etc.)
Vandalism (graffiti, destruction, damage, harm to property or personal belongings)
Online abuse (email, social media, etc.)
Hoax calls / abusive phone calls or text message / hate mail
Discrimination / unfair treatment (e.g. by landlord, doctor, teacher, employer, police officer or another service provider)
Displaying or spreading hateful symbols/ images / posters / literature
Systemic Harm
Prefer not to say
Other
Please upload any relevant photos or information you would like to include:
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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.)
Homophobia
Transphobia
Racism
Anti-Indigenous racism
Anti-Black racism
Xenophobia
Antisemitism
Islamophobia
Anti-immigrant hate (xenophobia)
Anti-Asian racism
Ableism
Prefer not to say
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?
Yes
No
Would you like someone to contact you to discuss and explore possible options for support and/or a restorative justice response?
Yes
No
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.
I prefer to be contacted by:
Email
Phone cal
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.
I understand
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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