Equality Cumbria:	AWAZ Cumbria:	Cumbria Disability Network:	OutREACH Cumbria

Incident Report Form

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Incident Reporting Form

Have you been a victim of Hate crime?

If you have suffered from verbal or physical abuse or your property has been vandalised or you feel you have been discriminated against, please report the incident.

Please try to fill in as much detail as possible.

All information provided will be treated as strictly confidential and will only be provided to a third party with your consent.

Date of incident
Time of incident
Name (preferable but optional)
Address (preferable but optional)
City/region/town

Contact Tel. No. (preferable but optional) (
Contact Email (required)
Location of incident
Details of incident (Please try to describe as much as you can of the attack, the attackers, the time of day etc, what was said to you, include detailed description of the events and surroundings

		Please include the following information as this will help us to monitor trends of incidents.
Ethnicity
Faith
Nationality

Was the incident reported to the Police or any other agency?		Yes No
If so, which?
What was the outcome?
Any additional comment or information you would like to add?
Date of filling in online form
Reported by (if being reported by a third party)
Would you be happy for us to report this incident to the Police on your behalf?		Yes No
Would you like to be contacted if you require any help, support or information?		Yes No