Name | Alias *

Are you reporting on behalf of yourself or another? *

Where did it happen? *Name of organization/event/and or city

When did it happen?

What happened?

What do you think should be done in response to this event to prevent it from happening again?

Have you shared this experience with the organization? *

Was there any retaliation taken towards you for sharing your experience?

Can you list the retaliatory responses you received?

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.

Select all that correspond to this event: *