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About the methodology
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an incident
Incident Report
Hate Speech Incident Collection Form
Step
1
of
9
11%
Introduction
Hello!
Thank you for sharing your experience with hate speech. Filling out this form should take around 15 minutes.
Please fill in the questions about a SINGLE event that you experienced. If you experienced multiple events, you must fill out a separate complaint for each.
1. Where are you located?
(Required)
Burma
Malaysia
Thailand
Other than Burma, Malaysia or Thailand
Where did the incident take place?
(Required)
In Burma
Outside of Burma
Where did the incident take place?
(Required)
In Malaysia
Outside of Malaysia
Where did the incident take place?
(Required)
In Thailand
Outside of Thailand
2.
(Required)
I saw something online that I believe is hate speech
I saw something in person that I believe is hate speech
You indicated the speech was online. What platform was used?
(Required)
Facebook
Twitter
WhatsApp
YouTube
Tik Tok
Snap Chat
Instagram
Other
3. The speech targeted the person/group on the basis of:
Race/ethnicity
Religion
Gender
Sexual orientation
Political affiliation
Disability
Skin Tone
Caste
Migrant status
Other
Other
You indicated that the speech discriminated against a person for something other than the listed options. What was it? List as many as relevant.
4. What evidence can you provide? (you can submit later if needed)
Screen shot / photo
Recording
Written testimony
Reports
Word of mouth
Other
If none of the options apply, please just click 'Next' or select 'Other' and fill in the details in the textbox below
Other
5. What was your role in this hate speech?
Victim
Witness
6. What results are you hoping for?
Better understanding of hate speech & discrimination
Better understanding of what legal action could be taken
Conflict resolution with the speaker
Raising awareness
Preventing future hate speech
Reporting this to the United Nations
Other
If none of the options apply, please just click 'Next' or select 'Other' and fill in the details in the textbox below
Other
7. Are you able to make a report to the police safely?
Yes
No
I prefer not to answer
8. If this is a problem that requires government intervention, would you contact them for help?
Not at all
Only if it was a life-or-death situation
I am not sure
Yes
Thank you for reporting the hate speech incident using our online form.
The next sections in this form are optional, and you may choose to skip them. However, we recommend that you complete them if you want to provide more information about the incident.
(OPTIONAL) About You
If you are comfortable, please share some personal information (information will be anonymized & stored safely).
9. My gender is
Male
Female
Other
9.1 My age is
Please select
12 to 17
18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 or over
To answer the following questions, simply fill out with your answer or put 'N/A'.
9.2 My ethnicity is
9.3 My sexual orientation identity is
9.4 My religious/spiritual identity is
(OPTIONAL) How do you feel?
If you are comfortable, please share how you feel.
10. The incident has impacted my sleep (sleeping more or less)
Not at all
Mildly
Moderately
Majorly
10.1 The incident has impacted my eating habits (eating more or less)
Not at all
Mildly
Moderately
Majorly
10.2 The incident has impacted my ability to leave my home
Not at all
Mildly
Moderately
Majorly
10.3 The incident has impacted my feeling of safety in my home
Not at all
Mildly
Moderately
Majorly
10.4 The incident has led to the use of intoxicating substances
Not at all
Mildly
Moderately
Majorly
Not applicable
10.5 Since the incident I fear for the wellbeing of the victim's or my community
Yes
No
I prefer not to answer
10.6 Since the incident I fear going online
Yes
No
I prefer not to answer
10.7 Since the incident I have changed my daily routine
Yes
No
I prefer not to answer
10.8 Since the incident I avoid talking to or seeing someone I believe is from the perpetrators group
Yes
No
I prefer not to answer
10.9 Since the incident I am feeling
Fine
Angry
Upset
Highly upset and I may harm myself or somebody else
If you are highly upset, and are considering harming yourself or someone else, please immediately contact:
Burma: ‘Call Me Today’ – Burma Phoneline Counselling operating on weekdays from 5 PM to 11 PM. -
09 782 383 145
Malaysia: Beyond Borders emergency Mobile and WhatsApp hotline -
012 3739419
Thailand: Samaritans emergency hotline -
02 713-6793
(OPTIONAL) About the perpetrator
11. Was the perpetrator of this crime known to you?
Yes
No
11.1 Was the perpetrator a man or a woman?
Man - Young
Man - Middle-aged
Man - Old
Woman - Young
Woman - Middle-aged
Woman - Old
Unknown
11.2 What is the perpetrator's relationship to you?
Spouse
Family member
Neighbour/Friend
Teacher/Educator
Intimate partner
Religious official
Aid worker
Foreigner/Westerner
Tourist
Security personnel
Official police/army
Journalist
No relationship
Other
11.3 What was the ethnicity of the perpetrator?
Rohingya
Bangladeshi
Malaysian
Thai
Burmese
Westerner
Other
11.4 Who did the perpetrator hurt? Please select ALL that apply:
They wanted to hurt me personally
They wanted to hurt another person
In what way did the perpetrator intend to hurt you?
They wanted to make me afraid
They wanted to force me to do something
They wanted to prevent me from doing something legal
In what way did the perpetrator intend to hurt the other person?
They wanted to make the person afraid
They wanted the person to do something illegal
They wanted to prevent the person from doing something legal
11.5 What do you think is the perpetrator’s intention?
They wanted to insult me
They wanted to provoke
They intentionally wanted to incite violence
They wanted to cause public fear or concern
They wanted to cause one group of people to commit an offence against another group of people
Final Steps
12. After completing this form, the information you entered will be sent to our APPAP country team. APPAP will not share this data without your consent. Are you comfortable with APPAP sharing your (anonymous) information?
(Required)
I consent to my information being used in complaints to social media platforms or the UN, but NOT in a public report
I consent to my information being used in complaints to social media platforms or the UN, or in a public report
I do not consent to APPAP sharing my data with anybody
13. Thank you for completing this survey. We are committed and equipped to follow up on your complaint.
I would like to pursue a remedy myself
I would like APPAP to help me file a complaint
We will contact you for further information, please enter your contact info below:
(Required)
Some of the people we notify about your complaint (e.g. local UN offices) may be interested in learning more about what happened. If this is the case, are you willing to speak with someone? (You always have the right to change your mind)
(Required)
Yes
No
About the organizations
About hate speech
About the methodology
Resources
Blogs
Menu
About the organizations
About hate speech
About the methodology
Resources
Blogs
Report
an Incident
