Section 1:
Name of Person Recording:
Organisation:
Telephone:
Email:
Address:
Incident Type:
Homophobic
Racist
Disablist
Faith and Religion
Other:
Section 2:
Name of Person Recording:
Telephone:
Address:
Gender:
Please choose
Male
Female
Transexual
Date of Birth:
Relationship to Victim:
Section 3:
Name of Victim:
Telephone:
Address:
Gender:
Please choose
Male
Female
Lesbian
Sexuality:
Please choose
Hetrosexual
Female
Lesbian
Bi-Sexual
Date of Birth:
Religion:
Preferred Language:
Victim considered disabled:
Please choose
Yes
No
If Yes, please specify:
Asylum Seeker:
Please choose
Yes
No
If Yes, Asylum Seeker Provider:
Victim Origin:
Victim Owner Occupier:
Please choose
Yes
No
Council - Housing Assocation - Private Landlord (specify):
Section 4:
Repeat Victim:
Please choose
Yes
No
Was the previous incident reported to any organisation:
Please choose
Yes
No
If YES, which organisation:
Ref No:
Section 5 (Details of the Incident):
Time:
Date:
Location:
Type of Incident:
Verbal
Physical
Damage
If Other, please specify:
Verbal, what was said:
Physical, what injuries were sustained by the victim:
Weapon used:
Please choose
Yes
No
If Yes, please specify:
Did the victim require medical treatment:
Please choose
Yes
No
If Yes, where treated:
What property was damaged:
Value of damage £:
Summary of Incident - Please include any information which appears relevant to this incident:
Section 6:
Did anyone see the Incident:
Please choose
Yes
No
If Yes, person seeing incident:
Address:
Telephone:
Alleged offender(s) known:
Please choose
Yes
No
If Yes, details:
How long the alleged offender known:
Section 7 (Details about the alleged offender(s)):
Number of alleged offenders:
Please choose
1
2
3
4
5
More Than 5
Offender 1
Gender:
Please choose
Male
Female
Transexual
Ethnic Appearance:
--> Choose
White British
White Irish
White Other
White/Back Caribbean
White/Black African
White/Asian
Mixed/Other heritage
Asian British
Asian Indian
Asian Pakistani
Asian Bangladeshi
Asian/Other heritage
Black British
Black Caribbean
Black African
Black/Other heritage
Chinese
Any Other Heritage
If Other, specify:
Language Spoken:
Religion:
Approx Age:
Height:
Build:
Hair Colour:
Style:
Feature:
Clothing Worn:
Marks:
Please choose
Tattoos
Scars
Offender 2
Gender:
Please choose
Male
Female
Transexual
Ethnic Appearance:
--> Choose
White British
White Irish
White Other
White/Back Caribbean
White/Black African
White/Asian
Mixed/Other heritage
Asian British
Asian Indian
Asian Pakistani
Asian Bangladeshi
Asian/Other heritage
Black British
Black Caribbean
Black African
Black/Other heritage
Chinese
Any Other Heritage
If Other, specify:
Language Spoken:
Religion:
Approx Age:
Height:
Build:
Hair Colour:
Style:
Feature:
Clothing Worn:
Marks:
Please choose
Tattoos
Scars
Section 8 (Vehicle Used):
Make:
Model:
Colour:
Registration:
Other distinctive features:
Section 9:
Has the incident been reported to any other organisation:
Please choose
Yes
No
If Yes, which organisation:
Ref No:
Complainant wishes to be contacted by another agency:
Please choose
Yes
No
If Yes, please specify:
Kirklees Neighbourhood Housing
Kirklees Race Equality Council
West Yorkshire
Other:
Section 10:
1. I give my consent for this information to be shared:
Please choose
Yes
No
2. Are there any organisations that you do not wish your details passed to:
Any additional information:
I have read the disclaimer (must be checked to send form)
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