Antisemitism Incident Report Form

If you have been the recipient of antisemitism, know someone who has, or if you have observed an antisemitic incident, we want to hear from you. Please fill out the form below to the best of your ability. It will help to inform us how to follow-up on or work to prevent these kinds of incidents locally. Items marked with a red * are required. Your identity and other information provided will remain confidential. When done, please click on the "submit" button at the bottom. Thank you for taking a stand against antisemitism.

First Name *

Last Name *

Email *

Phone *

Tell us why you are submitting this report (select one): *

This incident was something that (select one):. *

Date of Incident *

Month

Day

Year

This incident happened (select one)... *

If this incident happened in person, where did it occur (select one)?

If Other, please describe location:

Please describe the in-person incident (be as thorough as possible):

Is this an ongoing incident? *

If ongoing, what is date of first occurance?

Month

Day

Year

If this incident occurred in the media, please describe medium (select one):

Please describe the media incident (be as thorough as possible):

If this incident occurred online, please describe the platform (select one):

What kind of online content or activity are you reporting?

Who is the target of the online antisemitism? (name or group):

What is the target's screen name or handle?

Please describe the online incident (be as thorough as possible):

Please provide relevant links/web addresses to the offensive posts:

Have you reported the incident to the platform on which the incident occurred?

If Yes, what is the case number?

If known, provide the perpetrator's name/screen name:

What is your relationship to the perpetrator?

If the perpetrator has given you any indication of their motivation, please provide relevant details:

Have you contacted any law enforcement agency regarding this incident (in-person, media, or online)? *

If yes, which agency?

What follow-up or support would you like from the TBE Antisemitism Task Force? *

If available, upload supporting files (documents, photos, videos, rcordings, etc):

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Temple Beth El

Antisemitism Incident Report Form

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