REPORT AN ANTISEMITIC ACT OR CONTENT

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- Reporting antisemitic acts or content
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REPORT AN ANTISEMITIC ACT OR CONTENT

Reporting of antisemitic acts by victims

You have been a victim or witness of anti-Semitic acts! Please complete this form and we will contact you shortly.

COMPLETE THIS FORM
All fields marked with a white asterisk are mandatory
My personal data
Insert your personal data below which will remain strictly confidential and will never be used without your explicit consent.
Full Name
Enter your First and Last Name
Civility First name Middle name Name
Your street address
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Address 2 Line Address City Region Postal code Country
Your preference to be contacted*
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Your email address*
Enter your email address
Email Confirm your email address
Your telephone number*
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Portable
Your mobile
At what time slot would you like to be contacted?
Enter here the time slot you prefer to be contacted.
FACTS
Section describing the facts of which you were a victim or witness
I*
Have you been a victim or a witness? Click on the choice that corresponds to your situation
- Victim
- Witness
What type of anti-Semitic or racist act have you witnessed or suffered?
You have been the victim or witness of an anti-Semitic act. It is either a report for a slippage on the media or social networks, or an attack on the person.
- The report is about a human rights violation
- The report concerns the Media, Internet or Social Networksx
Date of the facts*
Enter the date of the facts of which you were a victim or witness
DD slash MM slash YYYY
Do you know the time of the facts?
Do you know the exact time of the events? If yes, tick yes otherwise tick no
- YES
- NO
Hour
Enter the time of the facts

: Hour

Minutes
Nature of the facts
Choose the type of facts you denounce
Location of the Facts
Address
Address 2 Line Address City State / Province / Region Zip / Postal Code Country
Additional information on the place of the facts if necessary
Enter here, if you consider it necessary, additional information on the place of the facts, for example: staircase, elevator .....
Nature and circumstances of the facts
You are requested to fill in this section precisely. This is essential for your complaint to be taken into account. Describe the nature of the verbal or physical insults, assaults or violence you experienced or witnessed
Your report concerns a human rights violation
Violation of human rights: insult, defamation, physical aggression, moral harassment, murder, theft...
Report of the authors:
Description of the authors, give all the details you remember even those that seem unimportant to you
Number of persons
Indicate the number of people who contributed to this crime
Size of perpetrators
Give the approximate height of the perpetrators
- Normal
- Small
- Large
Dress code(s)
If you noticed the authors' attire, give details here
Other information you think useful about the authors
Enter here any other information that you think is useful to describe the perpetrators: morphology, supposed origin,...
Your report concerns the Media, Internet or Social Networks
Media, Internet or Social Media Statement
Your report follows that you have:
You can choose one or more choices. To choose several choices click while pressing the Control key (Ctrl)
Media Type*
Select media type
- Poster
- Journal
- Radio
- Televisions
- Internet
- Social Networks
Media name*
Specify the name of the show, the channel, the newspaper, the link to the page of the site, Facebook, Twitter, Youtube etc...
Manager's name (if known)
If you know it, specify the name of the presenter, the journalist, etc,... Otherwise leave blank
Further information
Enter the following additional information here:
Have you filed a complaint?
Have you filed a complaint with an authority?
- YES
- NO
Who did you file a complaint with?
If you have filed a complaint, can you report to whom?
- Curator
- District Attorney
- Disciplinary authority
Did you have a medical examination related to this event?
- YES
- NO
By whom were you examined?
Select the organization that examined you following the facts.
- My personal doctor
- Medical Examiner
- Clinic or hospital
Number of ITT days prescribed
If so, indicate the number of ITT days that the doctor has prescribed for you
Following your filing of a prior complaint, I give power to the BNVCA to bring civil action alongside you.
- YES
- NO
If you have useful documents, upload them here
Add a document (Text, audio, video) Max(5MO)
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Your Comments/Questions
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REPORT AN ANTISEMITIC ACT OR CONTENT

REPORT AN ANTISEMITIC ACT OR CONTENT

Reporting of antisemitic acts by victims

COMPLETE THIS FORM

My personal data

FACTS

Location of the Facts

Your report concerns a human rights violation

Report of the authors:

Your report concerns the Media, Internet or Social Networks

Further information