Anti-Arab/Palestinian Racism Self-Reporting Form

The information provided will be used for data collection, education and advocacy purposes only. ACLA cannot respond to incidents that are reported to us via this form or act on your behalf. Please contact your local legal clinic, provincial law society or provincial human rights commission for legal information.

For more information on anti-Palestinian racism and anti-Arab racism please see our reports on these topics.

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What form of racism did you experience? (check all that apply) *
Required
Do you identify as Arab? Palestinian? Other? (check all that apply) *
Required
Do you identify with any of the following identities? (check all that apply) *
Required
Where did this racism occur? *
Required
Did this racism happen to you or someone else? *
Required
When did this experience happen (approximately)? *
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In which Canadian city did this incident occur? *
What did this racism involve (check all that apply) *
Required
Please describe your experience with racism (What happened, who was involved, what did you do, did you get a resolution etc)? *
Did you report your experience?
*
Required
If you answered yes, tell us who you reported to and what happened? *
If you reported, was the outcome satisfactory?
*
Required
If you did not report, tell us why you didn't report? (check all that apply) *
Required
How has this racist experience impacted you? (check all that apply) *
Required
Feel free to explain further how racism has impacted you. *
Was this your first experience with anti-Arab/Palestinian racism? *
Required
Is there anything else you would like to share with us? *
This survey is anonymous. You are welcome to voluntarily share your contacts with us for possible research purposes. No information provided will be attributed to you (ie we will not say who provided the information). 

Thank you for sharing your experience with us. We are sorry this happened to you. 
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