Student Incident Report Form : Report an Antisemitic Incident : Jewish Community Relations Bureau|AJC

Report an Antisemitic Incident

Dear Student,

Please complete the form if you have experienced or witnessed antisemitism in Kansas or Western Missouri. If you are unsure about whether an incident is antisemitic or not, please still fill out the form. We want to better understand the experiences of Jewish students so that we can best adapt our programming and response.

The information you provide is kept strictly confidential. JCRB|AJC will not take further action unless explicitly requested.

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Name (Required)

Email (Required)

Phone number (Required)

City (Required)

Date of incident (please be as specific as possible) (Required)

Location of incident (online or in person, please be specific.) (Required)

Please provide a detailed description of the incident or issue, with as many specifics as possible. (Required)

Did anyone else see this happen? (Required)

Do you have evidence of the incident? (Required)

Please upload any evidence you have of the incident.

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What steps did you take before contacting us? (like contacting a teacher/instructor, counselor, principal, parent, security, etc.) Please include details of the contact or conversation. (Required)

What remedy/solution are you seeking, if any? (Required)

Do you want to involve JCRB|AJC further?

I want JCRB|AJC to contact me to discuss further action.
I want to report the incident but do not want to involve JCRB|AJC further.