Incident Report Form

The Incident Report Form allows individuals to confidentially record details of any racial attack or discrimination they have experienced or witnessed.

Personal Information

Name (Optional)

Phone

Email Address

Nationality

Do you wish to remain anonymous?YesNo

Incident Details

Date of Incident

Time of Incident

Hours

Minutes

AM/PM

Location of Incident (street, building, area)

Town/City

County

Nature of the Incident

Verbal Abuse (racial slurs, offensive language)Physical Assault (pushing, hitting, etc.)Online Harassment (social media, email, etc.)Discrimination (denied service, unfair treatment)Property Damage (graffiti, vandalism, etc.)Other (please specify):

Description of the Incident

Please describe what happened in as much detail as possible:

Perpetrator(s) Information (if known)

Number of people involved

Description (gender, age, clothing, etc.):

Names (if known):

Witnesses

Were there any witnesses?YesNo

If yes, please provide names and contact details (if possible):

Impact on You

Physical injuryEmotional distressDamage to propertyOther:

Action Taken

Was the incident reported to the police?YesNo

If yes, provide reference/case number:

Any other action taken (medical help, complaint to authority, etc.):

Consent

Do you consent to share this information (anonymously if requested) for awareness, reporting, or legal purposes?YesNo

Confidentiality Statement *

All information submitted will be kept strictly confidential. Your personal details will not be shared without your consent.

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