Detailed report Email Fill out the form (3 minutes) You are Victim/ClaimantWitnessOther First name Family name Email address * Phone number Are you a CCIE member? * YesNo The victim, the claimant The victim is a personan establishment Gender WomanMale Date of birth Place of birth Country of birth Nationality Victim's address Number Place Alley Avenue Boulevard Intersection Roadway Path City Court Courtyard Esplanade Blind alley Passage Place Bridge Dock Roundabout Road Street Square Place Street name Postal code City/town When and where did the incident take place? Start date Time End date Number Place Alley Avenue Boulevard Intersection Roadway Path City Court Courtyard Esplanade Blind alley Passage Place Bridge Dock Roundabout Road Street Square Place Public or private Public placePrivate place Street name Postal code City/town Describe the facts as accurately as possible * The victim was AloneAccompanied The accused person (discriminator, aggressor, etc.) was AloneAccompanied The individuals involved Number of victims Number of witnesses Number of accused people What is the relationship between the victim and the accused person? Family In love Neighbourhood Far acquaintance No relationship Within the work context Administrative (public services) Administrative (police, prison) School (between students) Was the police present? YesNo Did the police notice the offense? YesNo Was the scene filmed? YesNo Smartphone, surveillance camera, etc. Type of incident Type of incident Insult Defamation Provocation, incitement to racial hatred Degradation Violence Discrimination Other Was there any material damage? YesNo Was there a work leave? No Less than 8 days More than 8 days The accused person (discriminator, aggressor, etc.) Do you know the accused person (discriminator, aggressor, etc.) YesNo The accused party is a personan establishment Gender MaleWoman Age (approximately) Profession Information Summary
