Are you reporting on behalf of yourself or another? *
Where did it happen? *Name of organization/event/and or city
Your answer
When did it happen?
MM
/
DD
/
YYYY
What happened?
Your answer
What do you think should be done in response to this event to prevent it from happening again?
Your answer
Have you shared this experience with the organization? *
Was there any retaliation taken towards you for sharing your experience?
Clear selection
Can you list the retaliatory responses you received?
Your answer
How is your mental & physical wellbeing as a result of your experience with racism? Do you need support? What kind of support do you require? * Allyship, Infinity spaces, training, introduction to therapist and or self care facilitators, etc.