Report an incident
Victim of violence?
Event of violence
About
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2
3
4
5
1. Your date of birth
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2 How do you define your gender identity?
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Female
Male
Female (trans* or with a trans* past)
Male (trans* or with a trans* past)
Cross-dresser/transvestite
Transgender
Transsexual
Non-binary/genderqueer/gender-fluid
Agender
Cisgender/non-trans
Intersex
I don't know
Other
More than one answer possible
2.1 Gender identity: other
3. Were you officially assigned another gender at birth?
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No
Yes
4. What is your sexual orientation?
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Heterosexual
Lesbian
Gay
Bisexual
Asexual
Pansexual
Other
5. How do you disclose your sexual orientation?
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I openly disclose my sexual orientation.
I avoid behaviour that could reveal my sexual orientation.
I decide on a case-by-case basis whether or not I want to openly disclose my sexual orientation.
When I meet someone new, I am initially cautious about disclosing my sexual orientation.
Generally speaking, where I live, I feel safe with my sexual orientation.
I don't think that people see my sexual orientation.
More than one answer possible
6. Where were you born?
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In Switzerland
In another country
6.1 In which country were you born?
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Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Ascension
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Democratic Republic of the Congo(Kinshasa)
Congo, Republic of (Brazzaville)
Cook Islands
Costa Rica
Ivory Coast
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor Timor-Leste
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Metropolitan Areas
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Great Britain
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and Mc Donald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Rep. (North Korea)
Korea, Republic of (South Korea)
Kuwait
Kyrgyzstan
Lao, People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, Rep. of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federal States of
Moldova, Republic of
Monaco
Montenegro
Mongolia
Montserrat
Morocco
Mozambique
Myanmar, Burma
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian National Authority
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Island
Poland
Portugal
Puerto Rico
Qatar
Reunion Island
Romania
Russian Federation
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Príncipe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia (Slovak Republic)
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and South Sandwich Islands
Spain
Sri Lanka
Saint Helena
St. Pierre and Miquelon
Sudan
Suriname
Svalbard and Jan Mayen Islands
Swaziland
Sweden
Switzerland
Syria, Syrian Arab Republic
Taiwan, Republic of China
Tajikistan
Tanzania
Thailand
Tibet
Timor-Leste (East Timor)
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
U.S. Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City State (Holy See)
Venezuela
Vietnam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna Islands
Western Sahara
Yemen
Zaire (see Congo, Democratic People's Republic)
Zambia
Zimbabwe
6.2 What year did you move to Switzerland?
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Please give the year only (for example, 1984). If you have moved to Switzerland several times, please indicate the year of your first move only.
7. Are you or have you ever been a sex worker?
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Yes
No
8. What date did the incident take place?
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If you are not sure, please give an approximate date.
9. What time did the incident occur?
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:
hours
minutes
If you are not sure, please give an approximate time.
10. Place and/or address of incident (please be as specific as possible)
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11. Where did the incident take place?
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At my house/flat
At someone else's house/flat
In the street/in a public area
At school
At work/place of training
In a restaurant or cafe
On a night out /at a party or nightspot
In a shop
In a healthcare establishment
In a public institution
On public transport/at a public transport stop
At a sporting/leisure event
In a park/forest/public toilet
On the internet/by email
By post/telephone
Other
11.1 Other: where did the incident take place?
12. Which of the following have you experienced on the basis of your sexual orientation, gender identity or gender expression?
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Insults and verbal abuse
Violent threats
Being followed
Physical violence (being pushed, hit, kicked etc.)
Injury with a weapon
Sexual harassment
Sexual assault (e.g. attempted rape)
Rape
Refused help in a healthcare setting
Refused help by authorities
Refused entry to a public place (entry to a bar, a taxi etc.)
Refused employment
Dismissal
Termination of a housing agreement or similar
Cyber-bullying
Online insults, verbal abuse or hate discourse
Other
12.1 Other: what happened to you?
13. Can you give more details about the incident?
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Please be as specific as possible.
14. How many offenders were involved?
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1 person
2-4 people
5 people or more
I don't know the exact number of people involved.
15. Did you know the offender(s)?
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Yes
No
Some of them
I don't know
Not disclosed
16. Is/are the offender(s) in a position of power in relation to you (e.g. a police officer, doctor, teacher etc.)?
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Yes
No
I don't know
17. Do you think that the offender(s) was/were under the influence of alcohol or drugs?
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Yes
No
Some of them were
I don't know
18. Do you think the incident took place due to one or more of the following characteristics applicable to you, or which the offenders believed apply to you?
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Gender/gender identity
Gender expression
Sexual orientation
Race/ethnicity
Nationality
Age
Disability
Sex worker
I don't know
Other
18.1 Do you think that your appearance at the time of the incident allowed the assumption to be made that you could be trans?
No
I try to attract as little attention as possible.
It depends on my look at a given time.
I specifically dress in a non-gender typical way.
I don't make an effort to avoid attention.
I have physical features that cannot be hidden (e.g. size).
Yes
More than one answer possible
18.2 Other: which feature may have led to the incident?
19. Why do you think that the incident is connected to the features mentioned above?
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Because the offender(s) said so.
The offender(s) knew/thought they knew my sexual orientation or gender identity.
The incident was preceded by threats or other incidents.
Because of the place (e.g. a gay bar).
I don't know.
Other
19.1 Other
20. Please explain in more detail why you think that the incident was connected to the features mentioned above.
21. Were you physically injured?
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Yes
No
Not applicable
21.1 Can you describe these physical injuries?
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22. Have you experienced any psychological after-effects due to this incident?
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Yes
No
Not applicable
23. Who did you go to for help following this incident?
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Family
Friends
LGBT organisation
Psychologist/psychiatrist
LGBT helpline (by telephone or email)
I didn't seek help.
Not applicable
Other
More than one answer possible
23.1 Other: where did you go to for help?
24. Have you reported the incident to the police?
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Yes
No
24.1 What reaction did you receive when you reported the incident to the police?
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Support
Objective response
Rejection, condescension
Ridicule, insults
Violence
Other
I don't know
More than one answer possible
24.2 Other reaction
24.3 Did the police consider the incident a hate crime?
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Yes
No
I don't know
24.4 What were the reasons for not reporting the incident?
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25. Is there anything else you would like to tell us about the incident?
Additional questions
The final six questions are not directly linked to your report, but they are extremely important for our work and for the anti-hate crime campaign. We would therefore be grateful if you could also answer these questions.
26. How many people live at your place of residence (approximately)?
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I prefer not to say
Less than 5000
5000 to 10'000
10'000 to 50'000
50'000 to 100'000
more than 100'000
27. Are you a member of one or more LGBT organisations? (e.g. Pink Cross, LOS, TGNS, Pink Cop, Network, Wybernet, Dialogai, Lestime etc.)
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Yes
No
I prefer not to say
28. What is the highest level of education that you have completed?
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No education completed
Primary/secondary school
Apprenticeship
Apprenticeship with vocational certificate (Berufsmatura/maturité professionnelle)
A-level/college (Matura/maturité)
University degree
Not applicable
I prefer not to say
29. What is your current occupation?
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I am at school (primary/secondary).
I am doing an apprenticeship.
I am in employment.
I am doing military/non-military national service.
I am studying.
I am self-employed.
I am unemployed/looking for work.
I am retired.
I am a housewife/house husband.
Not applicable.
I prefer not to say.
30. What is you monthly salary?
Net salary after deductions, rounded off to the nearest franc and stated in figures.
31. Contact
Do you want us to contact you about your incident, in order to discuss how to proceed? If so, please provide us your email address or mobile phone number.
