Victim/Witness

Are you (optional)

Victim

Witness

Third party

Other

If 'Other', please specify (optional)

Please provide the name of the centre (optional)

Motivation

What type of incident are you reporting?

Please select the type of incident

Disability

Race

Religion or belief

Gender identity

Sexual orientation

Other

If 'Other', please specify the personal characteristic that has been targeted

The incident

Describe the incident in your own words (optional)

Give as much detail as possible eg threats, assault, damage, abusive language used

Was the victim or anyone else injured (optional)

Please select if anyone was injured

Yes

No

Unsure

Please provide details (optional)

Did any loss or damage to property result from this incident? (optional)

Please select if any loss or damage occured

Yes

No

Unsure

Please provide more information (optional)

On what date did the incident happen? (optional)

Day

Month

Year

What time did the incident happen? (optional)

Hours (HH)

Minutes (MM)

Where did the incident happen? (optional)

Please type in a postcode or what3words reference to find the location, or move around the map to select

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Has something like this happened to the victim before? (optional)

Yes

No