Anti Discrimination Campaign form – Irish Council for Human Rights

Contact Details

Email: [email protected]

ICHR
The Black Church,
St. Mary’s Place,
Dublin 7, D07 P4AX

TAKE NOTE: Please be advised that if you fail to answer any questions or provide sufficient detail around the incident in question, your application may be disregarded.
Consent*
I understand and would like to proceed.

Details of alleged incident of discrimination
Date of incident*
MM slash DD slash YYYY
Name of business involved in alleged discrimination.*
Address of business involved in alleged discrimination*
Street Address Address Line 2 City State / Province / Region Postal Code Country
Why were you not wearing a face covering?*
Do you have an have an exemption from the requirement to wear a face covering?*
Please provide details*
Were the Gardai called?*
Do you have video evidence of the incident?*
Do you have a medical exemption certificate?*
If you do not have a medical exemption certificate, did you try to secure one?*
Please provide details*
Maximun 1000 characters.
If you have a medical exemption certificate, did you show a copy to the business involved in the alleged discrimination?*
In your own words, please provide a detailed description of the incident of alleged discrimination.*