Racist Incident - Report Form

       
  PART A
All Sections (1 - 8) must be completed
Section 1
a. Please tell us who you are:
The Victim (public) The Victim (an employee of
      Westminster City Council)		 A Relative, Friend, Guardian OR Carer Of The Victim
A Neighbour Of The Victim An Employer Or Work Colleague       Of The Victim A Witness

      Another Organisation (Please Specify) :

      Other (Please Specify) :
 
b. If you are not the victim, is this report being made with the knowledge of the victim ? Yes     No
 
Section 2
  Which Council service are you reporting against ? (Select more than one if appropriate)
Adult Education One Stop Services Adult Social Care & Health
Parking Services & Car Parks Children's Services Parks & Playgrounds
Community Transport Planning & Building Control Food Safety
Registration of Births & Deaths Housing Schools & Colleges
Leisure/Sport Street Lighting Libraries
Trading Standards Licensing Waste Collection & Recycling
      Other (Please Specify) :
 
Section 3.
  What Type Of Incident Are You Reporting ? (Select more than one if appropriate)
  Written Abuse Verbal Abuse, Threats Or Insults Malicious Telephone/Text
      Messages/Email/Faxes
  Targeted Noise Nuisance Physical Assault Damage To Property Or Vehicles
Including: Graffiti, Vandalism Or Arson
      Other (Please Specify) :
 
Section 4.
  Please give the date, time and location of the incident (or approximate details):
 

Date : DD/MM/YYYY

Time : HH:MM

Location/Full Address :

 
Section 5.
 

Please give a detailed account of the incident(s), including whether other victims were involved:
 
Section 6.
 

Please give us details of the alledged offender(s), if possible:

(For example, this can include names, ages, gender, addresses, descriptions or any other information that might help identify the alleged offenders).

 
Section 7.
  Have you reported the incident to any other agency (e.g. Police, City West Homes, School, etc) ? If so, please specify

 
Section 8.
a. Would you like the Council to take further action ?: Yes     No
 
b.

If YES, to help us take further action, please tell us what type of action you would like Westminster City Council to look at taking:

(Please note: Pending circumstances, the Council may be able to take further action if you agree in Part A, Section 8(c) to allow the Council to disclose your personal details to the organisations).
 
c. Do you give permission for personal information to be disclosed, or do you want to restrict disclosure to named organisations only ? Yes     No
 
  If YES, do you give permission for personal information to be disclosed to all organisations, or do you want to restrict disclosure to named organisations only ?
  All Organisations    
  Only NAMED Organisations (in which event, someone will contact you to ascertain those details)