Report discrimination

Have you been discriminated against? Have you been discriminated against? Yes No

First name

Last name

Email adress (also for answering)

Address: Street, street number

Address: Postcode and city

Information on bias / discrimination incident: When did the incident occur? (please state the date or period)

Information on bias /discrimination incident: Where did the incident occur? (please be as specific as possible)

You can describe the incident here: Short description

What could be the reason for discrimination? What could be the reason for discrimination? Racist ascriptions / ethnic origin Gender Religion or belief Disability Age Sexual Identity Caregiver status Social status Other reason, e. g. Language, skin colour, residence status, chronic disease, weight

In which area did the bias / discrimination incident occur? In which area did the bias / discrimination incident occur? Workplace Services (e.g. Bank, Shopping, Public transportation) Renting of accommodation Health services (e.g. Doctor’s offices, Hospitals) Education (e.g. Kindergarten, School) Authorities and Public administration Police and Judiciary Leisure (e.g. Clubs, Cinema) Public areas

Do you require a reply? If yes, please enter a valid e-mail address! Do you require a reply? If yes, please enter a valid e-mail address! Yes No