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Incident Reporting Form

Have you been the victim of direct or indirect anti-Muslim harassment or discrimination either at work, in the school or in public places? Report these incidents to MPAC to enable us log and take action where required. Such incidents of harassment or discrimination may be attitudes you encounter at job interviews, tones of voice, stares, teasing or inappropriate jokes, conversations which suddenly stop when you enter the room, subtle forms of exclusion, or inappropriate and frequent references to Islam and emotional “buzzwords" like Islamists, Islamic militants, Jihad/Jihadists, holy Jihad, Muslim Extremists, Muslim Terrorists, Fundamentalists, etc.

Please try to fill in as much detail as possible. MPAC respects your privacy & confidentiality and will not disclose your details to a third party without your prior consent. For more information, please contact us at alert@mpac-ng.org
Date of incident
Your Name
(preferable but optional)
Your Address
(preferable but optional)
Your Telephone Number
(preferable but optional)
Your Email
(preferable but optional)
Description
(please try to describe as much as you can of the attack, the attackers, the time of day etc, what was said to you)
Was the incident reported to the police or any other agency? Yes No
If so which?
What was the outcome?
Comments
(This can relate to the police treatment of your case, or any other general comments)
Date of filling in this form
Recorded by
(please indicate if you are not the victim and how you know about the attacks)
Would you be happy for us to include this case in our reports on abuses and discriminations against Muslims? Yes No
Would you like an MPAC case worker to contact you? Yes No
 

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