Hate Incident Reporting Form

Have you been affected by a hate incident (which can be any behaviour which is perceived by anyone to be motivated by prejudice or hate) because of your age, disability, faith, belief or non belief, sexual orientation, race, ethnicity, nationality or because you are transgender? If you have been affected or know someone who has, we want to hear about it. We need to know what''s going on so that we can help. By working together, we can put an end to hate crime. Please help us make Wales a safer place. We encourage hate crime to be reported directly to the police service but understand that you may not wish to, perhaps for personal reasons or you may feel that the incident is unimportant. You may not wish any immediate action to take place but by telling us that an incident happened we may be able to help avoid a repeat incident happening to you or someone else in the future. If the form below does not work, then please click the logo above and use the form on the Safer Wales Website. Thank you. Please provide as much detail as possible when completing this form. We will only pass on personal information if you agree by checking the box at end of this form.
Are you:	The VictimA WitnessA Third party*
What do you believe prompted this incident?	AgeDisabilityReligion, Faith, Belief, Non-BeliefHomophobiaRace, Ethnicity, NationalityTransphobia*
Where did the incident happen?
Postcode (if known)
When did the incident happen?
Time
Date
In your own words tell us what happened, giving as much detail as possible:
If you were injured or hurt, please give us details:
If any loss or damage to property occurred, please give us details:
Please describe the people you believe to be responsible (eg name, address, age, gender, ethnic appearance, clothing, accent, distinguishing marks, religion/faith/belief, jewellery etc..)
Did you know them?	Yes   No   Prefer not to say
If there was a vehicle used, please describe the vehicle eg colour, make, model
ABOUT THE VICTIM: If you are a witness or a third party and are completing this form, please provide an estimate where appropriate.
Gender	MaleFemaleNot surePrefer not to say*
Estimated age group	under 1617-2425-3435-4445-5455-64over 65Not surePrefer not to say*
Race, Ethnicity, Nationality (if known):
Religion/Belief/Faith (if known):
Sexual Orientation	LesbianGayBisexualHeterosexualNot SurePrefer not to say*
PERSONAL INFORMATION - Passing on your personal information will assist the police to make Wales a safer place, however we will only do so with your permission.
I agree that my personal information may be passed on to:	My local police   My local Victim Support Scheme   An appropriate support agency
Please note: Safer Wales will not pass on your details to a commercial enterprise or marketing company.
Your Name
Date of Birth (optional)
Your Address
Postcode
Your telephone number(s)
Your Email address:
Preferred method of contact	TelephoneMobileEmailVisit to above addressDo not contact me*
Preferred time to contact
If you've indicated that we may call your phone/mobile is it OK to leave a message?	Yes   No
An anonymous summary of your incident will be sent to your local police service to help put an end to hate crime.
*
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