Self reporting form Please complete the form below. Details of victim Name Address Age Gender Male Female Transgender Ethnic origin Sexual Orientation Special requirements Language spoken Hearing impairment Yes No Support required Lip speaker Other Preferred contact Mobile Text Home Mini-com 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 About the incident Description of incident Date of incident Date of incident Day 12345678910111213141516171819202122232425262728293031 Month JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Year 201320142015 Time Do you know why this happened to you? Race Gender Religion / Belief Sexual Orientation Age Disability Transgender Mental health About the person who did this 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? We would like to use some of the following agencies to try to sort things out for you. Yes No Police Citizens Advice Landlord Local Authority Other Please state How did you find out about this reporting scheme?