Incident Reporting Form

If you have experienced antisemitism / antizionism in the healthcare setting, please provide as many details as possible, and we will be in touch with you promptly to assist you in addressing the issue.

All information will be treated confidentially and no action will be taken without your consent.

*mandatory fields for reporting

First name

Last name

Phone

State

Setting of incident

Online

In person

Are you reporting a lived experience or witnessing of an incident?

My own experience

Witnessed experience

Location (can include a social media account, other online site or in person location such as a hospital or medical/healthcare facility). Please provide as much details as possible, including address.

Date of incident/issue (if ongoing, identify when you first became aware of the issue).

Day

Month

Year

Level of urgency

Emergency response required

Response from AZHA required within 24 hours

Response from AZHA required within 7 days

No response required - for our information only

Please describe the incident in as much details as possible.

Please send all evidence (e.g. screenshots/videos/audio recordings) to info@azha.org.au and put your name in the subject heading.