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Harassment Incident Report Form

This form can be completed by the person who is experiencing harassment, or an individual, or an agency (eg library, youth club), recording this on their behalf. You do not need to give your name and address when reporting harassment but we will need this information if you want us to take further action.

At the bottom of this page is a downloadable version of the form that can be printed out and returned by post.

Who is this report about?

If this report is about you, give us your details.

If this report is about someone else, give us their details.

If you do not know the answer to a question, or do not want to answer it, please leave it blank.

About the victim
1. Date form completed
2. Name
3. Address
4. Postcode
5. Telephone / Textphone
6. E-mail
7. Do you or the victim prefer to communicate in another language?	Yes Please specify:

Harassment is motivated by prejudice Please tell us which groups you belong to
8. Race and ethnicity
9. Gender
10. Age
11. Disability
12. Sexual orientation
13. Transgender
14. Do you feel you (or the victim) are being harassed because you or someone you are connected to (eg. partner) belong to one of these groups?	Yes No
15. If ‘yes’, please tick what type(s) of harassment	Ageist Disablist Homophobic Sexist Racist Religious belief Other
If other, please specify

Details of incident
16. Nature of incident (Tick all that apply)	Physical assault Name calling Offensive graffiti Offensive material Verbal abuse/threats Ridicule or humour Sexual intimidation/innuendo Damage to property Refusal to co-operate with service users or staff (eg because of age, race, gender, sexual orientation, religion or disability). Other
If other, please specify
17. Is this the first incident?	Yes (Go to question 20) No (Go to question 18)
18. Over what period of time have the incidents been occurring?
19. Details of incident(s), (including the date and where it took place).
20. Give the name and address of the person(s) (if known) who caused the incident. Please include any other information which would help identify the person(s) eg age.
21. Give the ethnic origin of the person(s) if known who caused the incident
22. Do you (or does the victim) consent to this form being sent to the Police (if appropriate)? If so do you (or the victim) consent to the Police contacting them?	Yes No Yes No
*This question is for Bristol City Council employees only* 23. What action have you taken in response to the incident? (Please refer to guidelines for completing this form)	Discussed the matter with team manager Discussed with perpetrator Referral to support agency Referral to the police Temporary withdrawal of service (contact service manager) Put training programme in place Removed graffiti (telephone 0117 922 2100) Used local procedures, eg No Secrets Policy, health and safety policies Other
If ‘Other’, please detail your response
24. Would you (or the victim) like us to ask a support agency to contact you (or the victim)?	Equalities and Community Cohesion team - 0117 922 2658 / 922 2329 SARI (Support Against Racial Incidents) - 0117 942 0060 DICE (Disablist Incidents and Crime Intervention) - 0117 377 2732 EACH (Educational Action Challenging Homophobia - 0808 1000 143 Or, if you like, you can contact them directly.
25. Is this report for information only or do you (or does the victim) want further action? If further action needed (in addition to Q.23) please detail what is required.	Information only Require action
This question is for the Equalities team only. 26. Please enter date when all actions completed.
27. Name and contact details of person reporting if reporting on behalf of someone else.

Remember do nothing without the consent of the complainant (unless child protection issues are raised) please refer to the guidelines for completion

This form will be sent as an e-mail to the Council Equalities Team
Click to send report

The data provided will be filed and stored securely by the recording officer. The data will only be disclosed to other council departments and/or agencies working to tackle harassment with the permission of the complainant/person reporting harassment except in special circumstances where we have a duty to share certain information (eg where child protection legislation requires it).

The data provided will only be kept for as long as is necessary to carry out the functions it is needed for unless there is a statutory requirement on Bristol City Council to keep these records longer, and then they will be destroyed securely.

Personal data will be processed in accordance with the rights of the data subject under the Data Protection Act 1998. For advice about the Data Protection Act 1998 please contact:

The Data Protection Officer for Bristol City Council on
Telephone 0117 922 2725
E-mail data.protection@bristol.gov.uk

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Harassment Incident Report Form

Who is this report about?

About the victim

Harassment is motivated by prejudice Please tell us which groups you belong to

Details of incident

related links

Harassment is motivated by prejudice
Please tell us which groups you belong to