Tell Us Explain The Incident You can use this form to report to Stop Hate UK any Hate Crimes you have experienced or witnessed. You do not have to give your details. If you do give your details, you can choose who you want us to pass them to (e.g. local Police, local support agencies). If you need help immediately, call the Police on 999. If you want to talk to someone about the Hate Crime you have experienced, call the Stop Hate Line 24-hours a day on 0800 138 1625. If you don’t want to report a Hate Crime but would like to contact us, you can email us at info@stophateuk.org You do not have to answer all the questions. Please give as much detail as you can, so we can monitor Hate Crimes better. What do you think was the reason for the incident? Disability Gender identity Race Religion or belief Sexual Orientation Are you a Please choose one Victim Witness Third-Party (required) What happened? Verbal abuse/name calling Physical assault (inc throwing things at you, spitting, hitting) Damage to your home or vehicle Arson Leaving rubbish/Throwing things at your home/vehicle Anti-Social Behaviour Threats/Intimidation (verbal or written) Written abuse (letter/text/email/internet) Graffiti Theft/robbery Burglary (breaking into your home) Sexual abuse/rape/indecent act Problem with the police Problem with an organisation Discrimination at work Other (specify) When did it happen? Please be as precise as possible.(required) Where did it happen? Please be as precise as possible, and give details of the nearest town or city as well as the location(required) What happened? Please give as much detail as possible. Was it part of ongoing incidents? Please choose one Yes No Was anyone hurt? If so, please give details. If items were stolen or damaged, what was the approximate cost of these? If any offenders were male, how many were there? If any offenders were female, how many were there? How old were they? Please choose one Under 12 12-18 18-24 25-40 40-65 65+ Not Known What do you think their ethnicity was? Please choose one Bangladeshi Indian Pakistani Other Asian Chinese Gypsy Traveller Black Caribbean Black African Other Black background White English White Welsh White Scottish White Irish Other White European Other White background Mixed Dual Heritage White & Asian Mixed Dual Heritage White & Black African Mixed Dual Heritage White & Black Caribbean Other mixed background Any other Prefer not to say If you chose other Ethnicity, can you state which? Can you describe them? e.g. hair colour and style, height, build, the clothes they were wearing, any recognisable features such as tattoos Do you know who they were? Please give their name and address if you can. How do you know them? (e.g. neighbour) Did they use a vehicle? If so, please give the make, model, colour, registration Did anyone see it happen? If so, please give any details you have Has the incident been reported to anyone else? Police Other Agencies Which agencies have you reported this to? Do you have a Police Crime Reference Number for the incident? Please give it here. If the incident has not been reported anywhere else, was there a reason for this? About the Victim We would like to know about the victim of the incident. If you are the victim of the incident, please give as much detail as you want. If you are a witness or a third-party, please give as much detail as you can. What is the victim’s ethnicity? Please choose one Bangladeshi Pakistani Indian Other Asian Chinese Traveller Gypsy Black Caribbean Black African Other Black background White English White Welsh White Scottish White Irish Other White European Other White background Mixed Dual Heritage White & Asian Mixed Dual Heritage White & Black African Mixed Dual Heritage White & Black Caribbean Other mixed background Any other Prefer not to say (required) If you chose other ethnicity, can you state which? What is the victims date of birth (approximately)?(required) What is the victim’s gender? Please choose one Male Female Prefer not to say (required) What is the victim’s sexual orientation? Please choose one Lesbian Gay Bisexual Heterosexual Prefer not to say What is the victim’s religion/belief? Please choose one Buddhist Christian Hindu Jewish Muslim Sikh Other religion, faith or belief None Prefer not to say If you chose other religion/belief, can you state which? Does the victim have a disability or health problem? Please choose one blind or visual impairment deaf or hearing impairment speech impairment learning difficulty or disability mental health condition mobility long term health condition or disability other not known none Prefer not to say If you chose other disability, can you state which? What type of housing does the victim live in? Please choose one Owner Occupier Local Authority or Housing Association Private Rented Other not known If you are the victim of the incident and want more help, please give your details here. Please choose one of the following three privacy choices: I do not want to give any further details, and do not want any contact from the Police, Stop Hate UK or any other organisations I want the victim’s details to be passed to the Police AND a local support agency I want the victim’s details to be passed to a local support agency. I do NOT want the Police to have the victim’s details. What is the victim’s name? What is the victim’s address? What is the victim’s phone number? What is the victim’s email address? Would the victim prefer to speak in a language other than English? Are there any other requirements the victim has when they are contacted? (e.g. using Text Relay, not leaving messages) Are there any other organisations the victim does NOT want us to pass their details to? Do we have consent to report to the relevant agencies on behalf of the victim? Yes No Unsure About You If you are not the victim, how do you know the victim? Please choose one Friend/Family Professional I don't know the victim, I just witnessed the incident If you are not the victim, what is your name? If you are not the victim, what is your address? If you are not the victim, what is your phone number? If you are not the victim, what is your ethnicity? If you are not the victim, what is your gender? Please choose one Male Female Is your gender the same as you were given at birth? Yes No If you are not the victim, what is your date of birth? Is there any other information you want to give us? How did you hear about Stop Hate UK? Please choose one Advertisement Council Housing office Internet search engine Leaflet Local Hate Crime reporting centre Newsletter Newspaper Police Poster Used Stop Hate UK before Word of mouth/recommendation Work Other Not known (required) cforms contact form by delicious:days
