1. Victim

Are you a

Victim Witness Other

If other please specify:

2. Hatred Motivation

What do you think motivated this incident?:

Please select Homophobic Race Disability Transgender Faith or Religious Belief

Please explain why:

If Other please specify:

3. Incident details

In your own words tell us what happened. Give as much detail as you can:

Was anyone injured as a result of this incident?:

Yes
No

If yes please give details:

Did you, or the victim, suffer loss or damage to any property?:

Yes
No

If yes please give details:

`

What is the approximate value of damage?:

£

Please tell us the time and date this incident happened. If you are not sure, please tell us between which time(s) and date(s) this incident happened:

Where did it happen? Please include area, town and street if applicable:

Have similar incidents happened before? Please give details:

4. Witness details

Did anyone witness what happened to you?:

Yes
No

If yes please give details:

5. Offenders

How many offenders were there?:

Did you know them? If so please give details including names and addresses, if known:

`

Can you describe the offender(s)? Give details including age, sex, height, build, hair colour, and clothing, if known:

What is their ethnic appearance?:

Offender 1: Please select White - North European White - South European Black Asian Chinese, Japanese or any other South East Asian Arabic or North African Unknown

Offender 2: Press select White - North European White - South European Black Asian Chinese, Japanese or any other South East Asian Arabic or North African Unknown

Offender 3: Please select White - North European White - South European Black Asian Chinese, Japanese or any other South East Asian Arabic or North African Unknown

Offender 4: Please select White - North European White - South European Black Asian Chinese, Japanese or any other South East Asian Arabic or North African Unknown

Offender 5: Please select White - North European White - South European Black Asian Chinese, Japanese or any other South East Asian Arabic or North African Unknown

6. Vehicle Information

Did they have a vehicle? If yes please give details.

Yes
No

If you don't know the make or model of the vehicle, please can you describe it:

7. Your personal details

Name:

Address:

Postcode:

Date of birth:

Gender:

Female
Male

Ethnicity:

Please select White British White Irish Any other White background Black Caribbean Black African Any other Black background Asian Indian Asian Pakistani Asian Bangledeshi Any other Asian background Mixed White and Black Caribbean Mixed White and Black African Mixed White and Asian Mixed Any other Mixed background Chinese Any other ethnic group Not Stated

Daytime telephone number:

Evening telephone number:

Mobile telephone number:

Email address: