Self reporting form Please complete the form below: Details of victim: Name: Address: Age: Gender: Ethnic origin: Sexual Orientation: Special requirements: Language spoken: Hearing impairment: Yes No Support required: Lip speaker Other: Preferred contact: Mobile: Text Home: Email: I do NOT wish to be contacted Type of incident: Graffiti Anti social behaviour Disputes Verbal Assault Abusive phone calls Hate mail Threats Theft Damage to property Harassment Arson Description of incident: Date of incident (If not specific, please estimate): Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2013 2014 2015 Time Do you know why this happened to you? Race Gender Religion / Belief Sexual Orientation Age Disability Transgender Mental health Do you know who they are? Yes No Are they male or female? Male Female What is their age? If you are NOT the victim, please complete this section: Name: Address: Contact Number: Have you reported to another agency? Police – Please state crime reference number if known: Citizens Advice Bureau Landlord Local Authority Other – Please state Permission Will you give us permission to speak to other agencies about your report? Yes No We would like to use some of the following agencies to try to sort things out for you. Please tick appropriate: Police Citizens Advice Landlord Local Authority Other (please state) How did you find out about this reporting scheme?