Offensive Incidents Report Form

An offensive incident is any incident which is perceived by the victim or any other person to be the result of hate or prejudice, as a result of the victim's gender, race, religion, disability, age or sexual orientation. Please be assured that all information received will be dealt with in the strictist confidence.

Please note that we may not be able to contact you or help with your request for service if your contact details are not correct.

Your Details:

Title, First Name and Last Name

Flat\Apartment number

Property\House number

Street name

Area\Town

Postcode

It is important that you enter a telephone number and/or an email address so that we can contact you if there is a problem.

Telephone\Mobile number

Email address

WHERE DID THE INCIDENT TAKE PLACE

Click here if same as above

House number (if applicable)

Street name\Location

Area\Town

SELECT WHY YOU THINK THIS IS AN OFFENSIVE INCIDENT. If you cannot identify one of the categories below, please report the incident on the anti-social behaviour form.

ADDITIONAL DETAILS ABOUT THE INCIDENT EG VERBAL ABUSE ETC

DETAILS OF YOUR GENDER

DETAILS OF YOUR HOUSING STATUS

YOUR DATE OF BIRTH

DETAILS OF YOUR SEXUALITY

DETAILS OF YOUR ETHNIC ORIGIN

DETAILS OF YOUR RELIGION

DETAILS OF YOUR DISABILITY IF APPLICABLE

DID ANYONE ELSE WITNESS THE INCIDENT? IF YES PLEASE GIVE NAMES AND ADDRESSES (IF KNOWN)

HAS THE INCIDENT BEEN REPORTED TO THE POLICE?

DO YOU HAVE AN EVENT NUMBER?

IF NO DO YOU WANT THE POLICE TO BE INFORMED?