Would you like to remain anonymous? *

If you choose to remain anonymous: You can still submit a report, but we may not be able to contact you for further information or keep you updated on any action taken.

Yes, I would like to remain anonymous

No, I am happy to provide my details

What would you like to report? *

Please select all that apply

Anti-social behaviour (ASB)

Hate crime

Hate incident

Not sure

Are you?... *

The person affected by the incident

Reporting on behalf of someone else

A witness to the incident

Has this happened before?

Yes

No

Not sure

How often has this happened?

Once before

A few times

Several times

Regularly

Ongoing/currently happening

Not sure

Do you know who was involved? *

Yes

No

How has this affected you/the person affected?

Please select all that apply

Feel unsafe

Feel anxious, stressed or worried

Home life has been affected

Health or wellbeing has been affected

Family or personal relationships have been affected

Daily activities or independence have been affected

Not sure

Other

Do you feel there is an immediate risk to your safety?

Yes

No

Do you believe this happened because of any of the following characteristics?

Please select all that apply

Disability

Race, ethnicity, nationality or cultural background

Religion, faith or belief

Sexual orientation

Gender identity or transgender identity

Sex or gender

Other characteristic (please provide details)

Not sure

Have you reported this to the police?

Yes

No

Have you reported this to any other organisation?

Yes

No