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Harassment Incident Report Form

Report Forms

Use the on-line version on this page or select the link below to view and print out a paper version:

Harassment Incident Report Form and Guidelines (PDF, 200K)

On-line Report Form

This form can be completed by the person who is experiencing harassment or an individual or an agency (eg area housing office, youth club) recording this on their behalf.

Who is this report about?
1. Is this about you (self-reporting), or are you reporting on behalf of someone else?	Self reporting Reporting on behalf of someone else

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

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.

About the victim
2. Name
3. Address
4. Postcode
5. Phone
6. E-mail
7. Do you or the victim prefer to communicate in another language?	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 are being harassed because you belong to one of these groups?	Yes No
15. If 'yes' to question 14, 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. Is it the same person who is harassing you?	Yes No
20. Details of incident(s), (including the date and where it took place).	*Required
21. 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.
22. Give the ethnic origin of the person(s) if known who caused the incident
*This question is for Bristol City Council employees only* Q23 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. Name 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

Data Protection

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 - advice and support

Harassment Incident Report Form

Report Forms

On-line 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

Data Protection

related documents

harassment - advice and support

Harassment Incident Report Form

Report Forms

On-line Report Form

Who is this report about?

About the victim

Harassment is motivated by prejudicePlease tell us which groups you belong to

Details of incident

Data Protection

related documents

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