Share your experience
Ithaca Asian American Association (IAAA) is a volunteer-based civic organization. It promotes, educates, and celebrates cultural heritage of Asian and Asian Americans. For more information, visit
or or Facebook: Ithaca Asian American Association. Contact:
With the increased number of racially motivated harassment incidents in the area (our community members have been called “virus,” told "go back to where you came from,” and “you are corona”), IAAA has developed this form so community members who have experienced bias or hate can report these incidents. Individual, personal information will only be shared with supportive members of the Ithaca Asian American Association. It will not be shared publicly unless permission is granted. The information gathered will be used to advocate for assistance, advocacy, and education. Your general report (without personal identification) will be shared with local law enforcement agencies and/or to appropriate agencies with your consent. The incident details will also be posted on various social media platforms to better inform the community and encourage others to tell their stories. If you have any concerns or questions, please do not hesitate to contact
. If the matter is urgent, please call 911.
Description of Incident *Please provide 2-3 sentences describing the incident.
Gender ( optional)
Date of the incident
Time of the incident
Site of Discrimination - where did it take place? include internet/online
Types of discrimination (Click all that apply)
Barred from establishment (e.g. restaurants, shops)
Barred from public transit (Lyft, Uber, Public bus)
Suspected Reason for Covid-19 Discrimination (Click all that apply)
Face Mask or Clothing
Would you like to make this incident public? If yes, it will be shared on social media. If not, it will only be shared with appropriate agencies and allies.
Any Supporting Links(News Clips, Social Media Sites)
By checking this box, you give IAAA permission to use your story, without personal information, for referral, service, and advocacy. We will not share your personal information publicly without your written consent.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service