Advocacy & Rights

REPORT A DISCRIMINATION CASE

This form can be used to report situations of discrimination in access to health services and to request guidance, a preliminary review, or support in approaching the relevant institutions.

Contact and reporting details

Fill in your identifying details and choose whether you want to submit the report anonymously. If you remain anonymous, contact fields become optional.

I want to remain anonymous

Personal data becomes optional.

Full name

Email address

Phone

Your role in this report

Incident context

Describe where and when the situation occurred, in what capacity you are submitting the report, and which circumstances are relevant for assessing the case.

City / County

Date of the incident

Medical unit / institution involved

Have you previously reported the matter to the institution involved or another authority?

If yes, specify which one and when

Detailed description of the situation

Consequences for the affected person

Available evidence

Check the types of evidence you already have and mention any other materials or information useful for the review.

Type of support requested

Indicate what kind of support you need from the SASTIPEN team for the next steps.

Declaration and data protection

Confirm the accuracy of the information provided and your consent for processing the data required to review the report.

I declare that the information provided is true to the best of my knowledge.

I consent to the processing of my personal data for the purpose of reviewing this report, in accordance with Regulation (EU) 2016/679 (GDPR).