Are you a
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
Telephone number

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
Sexual orientation / identity
Religion or belief - I am a
Political convictions/activities
Membership in a (sub)culture
Drug user
HIV positive / AIDS
Other reason

I am / the victim is

Woman / Man
Number of attacked people

The incident

Time of day
Town or city
Damages resulting from the assault

The perpetrator(s)

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

After the assault

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

I am giving my permission to In IUSTITIA, o.s. to process and store all the information listed above, personal data included. Given data will be used in compliance with valid legal regulations according to the Act no. 101/2000 Coll., on the protection of personal data and the Regulation of the European parliament and of the Council (EU) 2016/679. Privacy supervision will be conducted by The office for personal data protection, to which you can submit any suggestions or complaints.

Provided personal data will be processed for the purpose of surveying prejudice motivated violence in the Czech Republic. Aforementioned personal and contact details will be kept for a period of two years in the internal electronic database. This database is secured and accessible by authorized personnel only. After this period, data will be discarded. Other attack related information, will be kept anonymously. Attack related information are not transferred to any third party. Personal data are never released publicly. Other attack related details are published through a variety of research reports, which are available on the website In IUSTITIA, or in printed form. These reports do not disclose any information regarding attack notifiers.

This consent can be withdrawn at any time. After the withdrawal, all personal and contact details leading to your identification will be promptly discarded. Other attack related information will be kept anonymously. Withdrawal of your consent can be made via e-mail You have the right to know what personal data are being processed, and you can request their correction. You can request the discarding of your personal data.

We are not allowed to process or to store your personal data, without without your consent. If you want to allow In IUSTITIA access to the information, please check the box. Otherwise, attack information will not be processed.

Thank you, you have been a great help to us. If you have asked for help, someone from our organization will contact you soon.

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Justýna Counselling centre


Call us: +420 212 242 300
Write to:

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