Alliance Against Islamophobia (AAI)

AAI Reporting Form
I want to:*

Report a Real Life IncidentReport an Online IncidentReport a Matter Related to My Uni/Higher Education Provider
Are you lodging this complaint on someone else's behalf?*
Your personal details
Name

(Note: If you want to remain Anonymous type "Anonymous" in the first name field)
Name*
Mobile Number*
04xxxxxxxx
Email*
example@example.com
State
Postcode
Please provide the on behalf of contact details in relation to this submission.

You can contact on behalf of someone else. The person you are lodging this contact for must complete and return this form to allow us to discuss their contact with you. You may attach this form at the end of this contact or email it to support@comsaa.au. If they do not tell us you have their permission, we will not investigate your contact.
Title

DrMissMrMrsMsOther title
Name*
Mobile Number*
04xxxxxxxx
Email*
example@example.com
State
Postcode

Gender*
Current Sector*

GovernmentCorporatePrivateBusiness
Type of incident?*

Hate Speech/Verbal ThreatGraffiti/VandalismDiscrimination at workplace/school or by authoritiesTV, Radio and Print MediaNon-Verbal IntimidationPhysical AssaultWritten Materials Other (please specify)
Type of online incident?*

Smear campaign against a particular Muslim individual or an Islamic organisation/entityPoliticians’ statements (and their circulation)Organised action (boycotting, rallies… )MemeComment on a social media postPetition campaignInterpersonal harassment and intimidation Other (please specify)
Date of the Incident*

MonthDayYear
State*
Postcode*
Online platform*

Facebook, Facebook MessengerInstagramXYoutubeEmailWebsite/BlogUnknown Other (please specify)
Social media account name of perpetrator*
Provide the screenshot or link about the reported incident

I have a screenshotI have a link
Provide a screenshot about the reported incident

Cancelof
Link to incident
Who is filling out this form?*

VictimVictim’s friend/relative/proxyWitness/bystander
Victim’s gender?*

MaleFemaleRather not sayNot applicable Multiple victims (please specify)
Victim’s age group?*

Not applicable0-910-2021-3031-4041-5051-6060 or aboveMultiple victims (please specify)
Victim’s ethnic origin?

Not applicableArabIndian/Bangladeshi/PakistaniAfricanFrom Balkans & Near East (e.g. Turkey) or CypriotAfghanEuropean/AngloFrom Asia-PacificOther (please specify)
Was the victim wearing any religious clothing or other religious markers (eg. Jilbab, Hijab, kufi hat) at the time of the incident?

YesNoNot applicable
Perpetrator’s gender?*

MaleFemaleNot Applicable (in cases of graffiti/vandalism)Multiple perpetrators (please specify)
Perpetrator’s age?*

Not applicable0-910-2021-3031-4041-5051-6060 or above Multiple perpetrators (please specify)
Can you tell us about the incident? Please give details of what, where, when, it happened and what the perpetrator said and did? (Type below or upload an audio recording)*
Upload audio recording here (use voice recorder on your phone and use this field to upload)

Max. file size: 456 MB
Cancelof
Any other supporting documents

Max. file size: 456 MB
Cancelof
If you feel like you were affected by the incident, please select which emotions you felt?

Sadness/worry (unhappy, upset, concerned, nervous)Fear/being scared (panicking, feeling unsafe/insecure)Disappointment (despair, helpless, surprised/shocked)Anger (annoyance, fury, irritation, frustration, disgust, rage, Sickened etc.)Humiliation (shame and embarrassment)Other (please specify)
Can you tell us if the incident left any long-term impact? If so, what type of impact?
Have you reported to:

PoliceAnti-Discrimination BoardHuman Rights CommissionNoneOther (please specify)
Do you want the Register to forward your report to the Police?

YesNo
How can we help you? (please select one of the following)

Reporting onlyAdvice/advocacy assistanceReferral (counselling, legal support, social services etc)
Optional feedback
Do you want to receive CoMSAA's communication in the future?*

YesNo
Please provide the name of the Higher Education provider you are lodging a complaint about*
Have you complained to the provider?
Please advise the reason(s) for not making a complaint to your provider
Student ID number, if available
Are you a domestic or international student?
Are you a current student, previous student, or are you planning to study with this provider?
What level of study were you planning on undertaking with this provider?
What is your mode of study?
What is the name of the course?
Outline the details of your complaint
What contact have you had with the provider about the issue?
What outcome are you hoping for?
Does the person you are lodging this complaint for identify as any of following?
Are you a person with a disability or accessiblity requirements?
Please tell us if you require any support from us to interact with you more effectively
Do you require an interpretor or translator?
Which language your prefer?
Attachments

We usually ask students to send us a copy of their formal complaint and/or internal appeal correspondence with their education provider. If you give us this correspondence now, it will help us assess your complaint. Note: you can only upload a maximum of 20 MB.
Cancelof
Consent to transfer
Important: We may be unable to progress or resolve your complaint without sharing your information with other agencies. The Office will be in contact to provide further information on this process and answer any questions you may have.
Should be Empty:

AAI Reporting Form

Your personal details

Please provide the on behalf of contact details in relation to this submission.