Hate Crime reporting Are you: A victim? A witness? Other concerned person? About you: Your age: 0-9 10-16 17-24 25-34 35-49 50-64 65-74 75+ Your gender: Male Female Other Did the incident(s) happen because of? Race or ethnicity Disability Religion or belief Age LGBT status Tick all that apply (real or perceived) Please help us to monitor prejudice by telling us eg: actual race/ethnicity, disability type, religion or belief, age, LGBT status, gender here: Location - Where did it happen? Home School/college Public transport Shops On-line Other Tick all that apply Please help us to map incidents by telling us the actual location here: About Perpetrator(s) Approximate age: 0-9 10-16 17-24 25-34 35-49 50-64 65-74 75+ Gender if known: Male Female Other tick all that apply Details of the incident Verbal abuse: Low Medium High Including threats? Physical abuse: Low Medium High Including threats? Other: Mugging Burglary Property damage Other tick all that apply Please give Details of incident(s) eg: One off, repeat, by one or more people, when, what happened, race or ethnicity of perpetrator. Have you reported the incident(s) to the police? Yes I did report – please insert details of when you reported, what action is being taken? If you did report could you describe the experience and if you would report in the future? No I did not report – if no, please explain why you did not report to the police? If you did not report what did you do instead of reporting and how did that made you feel? What should be done to tackle the problems reported above? DATA PROTECTION All the information you give us is confidential. We may use it anonymously to help in our research and to improve services for victims. We would not use the information you give us if doing so identifies you in any way. Personal Information – you DO NOT need to fill this part if you want to remain anonymous. Filling in this part of the form will allow BD Citizens Advice Bureau to contact you confidentially. Please use the tick boxes below to tell us what contact you want: provide confidential and independent advice, information, support and help log my form and details in case I need help laterprovide confidential and independent advice, information, support and help I might help you with future research (e.g. focus group or interview) log my witness details in case the victim comes forward and needs evidence other reasons Title: Mr Mrs Ms Other First name: Surname: Address: Postcode: Telephone: Email: Thank you for your time. This information is confidential. If you have any queries at all please call BD Citizens Advice Bureau Hate Crime Project on 020 8507 5968 or email us at email@example.com.