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When did the incident happen? (Add dates and times if you can.)*

Where did it happen to you? (Add dates and times if you can.)*

Who was involved? (Please add names and addresses if you know them, or a description of the person.)*

What was your involvement?*

What happened? (Write down what happened and how this has impacted you)*

Have you reported this before?*

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No

Have you reported it to the police?*

Yes
No

If so what was the incident number and police officer’s details

Do you have video files that relate to this case. If so please tick the box below and a member of a team will contact you*

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No

If you have any files that relate to this case, please upload them here (Max Size 10MB - accepted file JPG,PNG,PDF,MP3)

Accepted file types: jpg, jpeg, pdf, png, mp3, mov, flv, mp4, Max. file size: 10 MB.

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Our Privacy Notice sets out how we look after your personal data and will provide you with further information about your rights

In some cases we would like to make contact with the person/s identified above to make them aware of the reported behaviour and give them an opportunity to comment about the allegations and the opportunity to work towards resolving the behaviour; where appropriate. *I am happy for you to contact the person/s identified as responsible for the antisocial behaviour*

Yes
No

I am happy for you to disclose my identity to the person/s identified as responsible for the antisocial behaviour *If no, please be aware that this may limit our ability to investigate your report or agree any form of action and although we will not disclose your identity if you do not want us to, we cannot stop people from making assumptions*

Yes
No

I am happy for you to discuss my report with other partner agencies (in may be worth including who these maybe and further details on why) *To help us deal effectively with ASB we work closely with other partner agencies such as the police, local authority and Youth Offending Teams etc*

Yes
No

Please be aware that where we have a duty to pass information to a statutory agency such as the police or Social Services, such as where a child is at risk, we will be speaking directly to the relevant agency giving full details of the situation*

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I confirm the details I have completed in this form are accurate and true to the best of my knowledge and belief *

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