Report an antisemitic incident INSTRUCTIONS: Use this form to document antisemitic incidents that you have witnessed or personally experienced. If a friend or family has told you about an antisemitic incident, encourage them to fill out the form as well. Please indicate if you are reporting an incident on someone else’s behalf. You can submit multiple reports. ALL FORMS ARE KEPT CONFIDENTIAL. Your contact information is used internally for follow-up questions and/or to offer support. *Required Contact Information: Please provide your contact information, in case we need to contact you for clarifications and/or action follow-up.Contact InformationYour Name *Email Address *Parent’s Email Address Your Phone Number *Parent’s Phone Number Are you a high school student? *YesNoWhat year are you in high school? FreshmanSophomoreJuniorSeniorN/AAre you a college student? *YesNoWhat year are you in college? FreshmanSophomoreJuniorSeniorN/AAre you a concerned parent or non-student community member? *YesNoDescription of Incident Please describe what happened. Be as specific as possible. Provide exact quotes and examples, if possible. When Did This Happen? *Where Did This Happen? * Note: Please provide the name of the institution, i.e. the name of the high school, college campus, community center, etc. If this happened online, please indicate the social media platform, i.e. Instagram, Facebook, Twitter, other. Did this happen to you? *YesNoWas a teacher or professor present? *YesNoWas the principal or a school administrator notified? *YesNoN/ADo your parents know about the incident? *YesNoN/AIf this incident happened to somebody else, please explain to whom and how you heard about it. *In your own words, please describe what occurred. *Has there been any action since the original incident? If so, please describe below. *Photos and Videos Please email any photos and videos documenting the incident to masha@clubz.org with the subject line: "Antisemitic Incident Report” Anything else you'd like to add *About YouDo you participate in any of the following groups? Club ZBBYOUSYNCSYOtherWhat other Jewish organizations are you involved in? VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank:
