Notification Form for Discrimination Incidents

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Magdeburg-Stendal University of Applied Sciences is responsible for the collection of information about incidents of discrimination. This information will be used to produce an overall report. This report is used by the network “RESPEKT” to demand action against discrimination and participation.

The discrimination concerned

myself

another

I personally observed / overheard I was told by:

family members friends someone I know colleagues clients other

What happened?
Who did what? What did others (not) do? What exactly was the discrimination?

Where and when did it happen?

in (place)

Month and Year

I saw / experienced this discrimination in the last year

once occasionally often

Please enter an approximate number of times

In which area of life did the discrimination occur? work / training / education

Nursery / Kindergarten Afterschool care (Hort) Primary School (Grundschule) Secondary School (Sekundarschule) Grammar School (Gymnasium) Vocational School (Berufschule) University (Hochschule) Language School additional training / re-education internship job search / job application Training Company (Ausbildungsbetrieb) Company / Employer other

Public / leisure / private life

Bus / Train Club / volunteer work Sport as a renter / property purchase family / friend / neighborhood / someone you know in the street other

services, health and shops

business / industry mobile social services / old age or care home, live in care centre chemist / doctors / hospital healthcare / long term care / or pension insurance office other

Offices / Authorities / Services

Job Center / Employment Office Social Welfare Office (Sozialamt) Youth Office (Jugendamt) Health Ministry (Gesundheitsamt) Office for Foreigners (Auslländerbehorde) Registry Office (Standesamt) / Citizen’s Office (Bürgeramt) / Citizen’s Registration Office (Einwohn Legal Office (Rechtsamt) Office for Building Construction (Hochbauamt) and Facility Management (Gebäudemanagement) Audit Office (Rechnungsprüfungsamt) School and Culture Office (Schul- und Kulturamt) Department of Building (Bauordnungsamt) Road Works Office (Straßenbauamt) Environment Office (Umweltamt) Public Order Office (Ordnungsamt) Public Food and Veterinary Office (Veterinär- und Lebensmittelüberwachungsamt) Economic Development Office (Amt für Wirtschaftsförderung und Projektmanagement) other

Media / Internet / Social Media

TV, Radio Chatroom, Facebook, Twitter, Instagram newspapers, magazines books advertising other

other

Other comments

I hereby certify

* The correctness of my information

* With the submission of this form I declare that I accept that my data or data relating to my person will be used by the Hochschule Magdeburg-Stendal. It will not be supplied to third parties. I am aware that I can withdraw my consent for future access at any time. I can do this via an e-mail to info@respekt-netzwerk.de, or via post to the Hochschule Magdeburg-Stendal, z.H. Maike Simla, Osterburger Str. 25, 39576 Stendal. The data protection regulations of this Website apply.

I agree to allow my report to appear in anonymous form in the annual report.

Yes No

Should we make contact?
It is possible to make a report without giving details.

Yes

I can be reached by the documentation office in the following way

first/given or made up name

e-mail or phone number

Completed information

Fields marked with a * are required

It is possible to make a report without giving details.

Information

More information about sharing incidents and the work of the RESPEKT network

Notification Form for Discrimination Incidents

Contact

Legal Information

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