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

Your Information:

Name:

E-mail:

Phone:

Home Address:

Gender:
Ethnicity:

Religion:

Please provide a detailed description of the incident below. Include date, location, time, witnesses, and any evidence of religious discrimination:

Offending Party’s Information:

Name:

E-mail:

Phone:

Address:

Business/Affiliation:

Gender:
Ethnicity:

Religion:

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Modified: June 24, 2014

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