DICE Harassment Incident Report Form

1. Harassment Incident Report Form

This form can be completed by the person who is experiencing harassment, or an individual, 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.
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.

Question Title

* 1. About the Victim:

Date Form Completed:

Name:

Address:

Postcode:

Telephone/Textphone:

Email:

Do you or the victim prefer to communicate in another language?

Yes

Please specify:

Question Title

* 2. Harassment is motivated by prejudice -
please tell us which groups you belong to

	Race and Ethnicity	Gender	Do you consider yourself a disabled person?	Please Indicate your age	Faith and beliefs	Do you identify as
Race and Ethnicity Monitoring	Race and Ethnicity Monitoring Race and Ethnicity menu	Race and Ethnicity Monitoring Gender menu	Race and Ethnicity Monitoring Do you consider yourself a disabled person? menu	Race and Ethnicity Monitoring Please Indicate your age menu	Race and Ethnicity Monitoring Faith and beliefs menu	Race and Ethnicity Monitoring Do you identify as menu

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* 3. 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

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* 4. If ‘yes’, please tick what type(s) of harassment

Ageist

Disablist

Homophobic

Sexist

Racist

Religious belief

Other

Other (please specify)

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* 5. Details of incident - please 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 (please specify)

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* 6. Is this the first incident?

Yes

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* 7. Over what period of time have the incidents been occurring?

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* 8. Details of incident(s), (including the date and where it took place).

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* 9. 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.

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* 10. Give the ethnic origin of the person(s) if known who caused the incident

	Ethnic Origin
Please use drop down menu	Please use drop down menu Ethnic Origin menu

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* 11. 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

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* 12. This question is for WECIL employees only

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

Other

If other please detail your response

Question Title

* 13. 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.

Question Title

* 14. Is this report for information only or do you (or does the victim) want further action?

Information only

Action required

If further action needed please detail what is required.

DICE Harassment Incident Report Form

1. Harassment Incident Report Form

Question Title

* 1. About the Victim:

Question Title

* 2. Harassment is motivated by prejudice -
please tell us which groups you belong to

Question Title

* 3. 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?

Question Title

* 4. If ‘yes’, please tick what type(s) of harassment

Question Title

* 5. Details of incident - please tick all that apply

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* 6. Is this the first incident?

Question Title

* 7. Over what period of time have the incidents been occurring?

Question Title

* 8. Details of incident(s), (including the date and where it took place).

Question Title

* 9. 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.

Question Title

* 10. Give the ethnic origin of the person(s) if known who caused the incident

Question Title

* 11. 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?

Question Title

* 12. This question is for WECIL employees only

What action have you taken in response to the incident?
(Please refer to guidelines for completing this form)

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* 13. Would you (or the victim) like us to ask a support agency to contact you (or the victim)?

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* 14. Is this report for information only or do you (or does the victim) want further action?

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* 15. This question is for the DICE team only.
Please enter date when all actions completed.

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* 16. Name and contact details of person reporting if reporting on behalf of someone else.

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* 1. About the Victim:

Question Title

* 2. Harassment is motivated by prejudice - please tell us which groups you belong to

Question Title

* 3. 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?

Question Title

* 4. If ‘yes’, please tick what type(s) of harassment

Question Title

* 5. Details of incident - please tick all that apply

Question Title

* 6. Is this the first incident?

Question Title

* 7. Over what period of time have the incidents been occurring?

Question Title

* 8. Details of incident(s), (including the date and where it took place).

Question Title

* 9. 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.

Question Title

* 10. Give the ethnic origin of the person(s) if known who caused the incident

Question Title

* 11. 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?

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* 12. This question is for WECIL employees only What action have you taken in response to the incident?(Please refer to guidelines for completing this form)

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* 13. Would you (or the victim) like us to ask a support agency to contact you (or the victim)?

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* 14. Is this report for information only or do you (or does the victim) want further action?

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* 15. This question is for the DICE team only.Please enter date when all actions completed.

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* 16. Name and contact details of person reporting if reporting on behalf of someone else.

* 2. Harassment is motivated by prejudice -
please tell us which groups you belong to

* 9. 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.

* 11. 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?

* 12. This question is for WECIL employees only

What action have you taken in response to the incident?
(Please refer to guidelines for completing this form)

* 15. This question is for the DICE team only.
Please enter date when all actions completed.