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Covid-19 - Incident Report
First name
Last name
Email Address
Date of Incident
Location of incident
Type of discrimination
Verbal Harassment/Name Calling
Physical Assault
Barred from establishments (restaurants/shops)
Barred from transportation (e.g. bus, taxi)
Workplace discrimination
Other
Suspected Reason for Covid-19 Discrimination
Race
Ethnicity
Gender
Language
Religion
Food
Face mask or clothing
Description of Incident
Can we share this information with STOP AAPI HATE Reporting Center established by the Asian American Pacific Islander (AAPI)
Yes, I give permission to share my incident information with the AAPI Civil Rights Organizations
No
I have questions or concerns; please contact me to provide more information about this reporting option.
