Report Discrimination

If you or someone you know has been a victim of an anti-Muslim hate crime or an act of discrimination, submit this form to have your case reviewed by the CAIR-Philadelphia civil rights department. Please note that your identity will remain confidential.

Your Information:

Name:

E-mail:

Phone:

Home Address:

Gender:
Ethnicity:

Religion:

Offender Information (if applicable):

Name:

E-mail:

Phone:

Business/Affiliation:

Address:

Gender:

Description of Incident:

Date of Incident:

Location of Incident:

Triggering Factor:

Describe incident in detail:

 

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