Questionnaire

Questionnaire
Are you a
HELP
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

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


Name / Nickname
HELP
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
Nationality / membership in an ethnic group
HELP
Sexual orientation / identity
Religion or belief - I am a
HELP
Age
Political convictions/activities
Membership in a (sub)culture
Disability
Drug user
HIV positive / AIDS
Homelessness
Other reason

I am / the victim is


Citizenship
Woman / Man
Age
Number of attacked people

The incident


Date
Time of day
Town or city
Region
Location
HELP
Method
HELP
Damages resulting from the assault
HELP

The perpetrator(s)


Were you acquainted prior to the incident?
Number
Members of the extreme right?
Description of the perpetrator(s)

After the assault


Did you report the assault to anyone?
If yes, to whom?
HELP
If no, why not?
HELP
What is happening with your case now?


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



fondnnomaly      •                 

Justýna Counselling centre

FREE LEGAL ADVICE

Fill in: ONLINE FORM
Call us: +420 212 242 300
Write to: poradna@in-ius.cz

Were you attacked because of:
- your ethnic or national origin
- your religious belief
- your sexual orientation, gender identity
- your affiliation to a social group?

Was the attack in a form of:
- verbal abuse
- property damage
- intimidation, threats or blackmail
- sexual assault
- arson
- physical assault
- homicide?

Don´t keep it to yourself!

Contact Justine, our legal counseling center.

We help you:
- to find your way in post-attack situation
- to file a complaint
- to communicate with police
- to assign a claim for damages
- to look for non-legal ways how to cope with assaults

We accompany you through criminal and administrative proceedings

Česky / English