Critical Incident Report Form- NO INCIDENT IS TOO MINOR TO REPORT

To be filled by person victim of critical incident of discrimination, hate and/or racism or someone who has witnessed a critical incident of
discrimination, hate and/or racism. This report is anonymous with
no direct action/support ("I just wanted you to know this happened")
or get further advice on raising the matter formally or receiving support
("I want something done", "I am upset/isolated by the experience and
need support").

Please write as much or as little as you want.

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* 1. Who is reporting this incident?

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* 2. Describe what happened.

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* 3. Was this an incident of discrimination, hate and/or racism?

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* 4. Was it on grounds of:

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* 5. Where did it happen?

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* 6. When did it happen? (date/time)

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* 7. Was this the first or a repeat incident? If repeat, over what period of time?

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* 8. Who was involved? (For example, provide relevant details of the victim, perpetrator and any witnesses such as their gender, age or ethnic origin and whether they were a member of staff, a councillor, a customer, or a member of the public. Please do not provide names because direct action cannot be taken as a result of this report).

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* 9. Have you told anyone else? Has any action been taken? What was the outcome? Please describe:

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* 10. Will you, or did you, make a formal complaint or grievance and when?

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* 11. If you have made a formal complaint or grievance, has it been resolved satisfactorily?

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* 12. Is there anything you would like to be considered in terms of areas for improvement or awareness raising?

0 of 12 answered
 

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