Questionnaire

Are you a

--- victim witness friend of a victim parent of a victim teacher social worker NGO worker network NGO Tourist/visitor [ other ]

Please describe the hate crime incident in detail. Try to answer the following questions: WHO, WHAT, WHEN, WHERE, WHY and HOW the perpetrator attacked you, and WHAT THE CONSEQUENCES WERE / ARE

Are you seeking

--- General information on hate crime Legal aid as an individual Psychological assistance Other assistance Nothing / I am just reporting the attack

If you would like us to contact you, please provide your contact information below.

Name / Nickname

Telephone number

E-mail

It is very important for us to learn as much information as possible about the incident you are reporting, as it will help us to better assist you and to document the overall state of hate crime in the Czech Republic. It should not take you more than five minutes to complete this questionnaire.

To be completed voluntarily

This attack occurred because of your

Race / skin color

Yes

No

Nationality / membership in an ethnic group

--- Roma Vietnamese Russian Ukrainian Slovak Mongolian English speaker [ other ]

Sexual orientation / identity

--- Heterosexual LGBT - gay LGBT - lesbian LGBT - bisexual LGBT - transgender

Religion or belief - I am a

--- non-believer Christian Muslim Jew Buddhist Hindu Sikh [ other ]

Age

Yes

No

Political convictions/activities

Yes

No

Membership in a (sub)culture

Yes

No

Disability

Yes

No

Drug user

Yes

No

HIV positive / AIDS

Yes

No

Homelessness

Yes

No

Other reason

I am / the victim is

Citizenship

a Czech citizen

an EU citizen

citizen of a non-EU country

Woman / Man

Woman

Man

Age

--- 15 or under 15-18 18-25 25-35 35-45 45-55 55 or over

Number of attacked people

The incident

Date

…

Time of day

--- 6 AM - 6 PM 6 PM - 10 PM 10 PM - 6 AM [ unknown ]

Town or city

Region

--- Prague Central Bohemia Region Southern Bohemia Region Pilsen Region Karlovy Vary Region Usti Region Liberec Region Hradec Králové Region Pardubice Region Vysočina Region Southern Moravia Olomouc Region Moravian-Sileasian Region Zlín Region [ outside the CZ ]

Location

--- At home In a public space (street, parking lot, etc) At school At work At a sports ground At a church/synagogue/mosque/temple At a club/bar/restaurant In a shop On the Internet [ other ]

Method

Verbal assault in person (offensive language face to face) Verbal assault via e-mail or post Verbal assault by telephone Intimidation or threats in person Intimidation or threats by telephone Intimidation or threats by e-mail or post Vandalism (damage to buildings, property) Graffiti Graffiti on religious buildings/cemeteries Physical assault without a weapon Physical assault with a weapon Arson attack Bomb attack Rape / sexual assault Murder / manslaughter [ other ]

Damages resulting from the assault

Moral harm Psychological harm / insomnia, fear, anxiety, nightmares Property damage less than CZK 5 000 Extensive property damage up to CZK 50 000 Large-scale property damage above CZK 50 000 Physical injury requiring up to seven days of treatment Physical injury requiring more than seven days of treatment Permanent physical damage Death [ other ]

The perpetrator(s)

Were you acquainted prior to the incident?

Yes

No

Number

One

A group

I don't know

Members of the extreme right?

Yes

No

I don't know

Description of the perpetrator(s)

After the assault

Did you report the assault to anyone?

Yes

No

If yes, to whom?

--- The police The state attorney The school A doctor My family A friend The media

If no, why not?

I have no faith in the police / state authorities I don't know who can help me I am ashamed to have been assaulted I just wanted to forget about the assault as quickly as possible

What is happening with your case now?

--- An official investigation is underway The investigation has been postponed / halted - the police are no longer working on the case A trial is underway The trial has been completed Nothing is happening I don't know

I agree that the organization In IUSTITIA, o.s. may process my personal, sensitive information as defined under Law No. 101/2000 Coll, on the protection of personal information.

Thank you, you have helped us a great deal. If you have requested specific assistance, someone from our organization will be contacting you soon.