Partnership Approach to Racial Incidents in North Staffordshire
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Self reporting form

REPORTING A RACIST INCIDENT

If you are a victim or a witness to racial harassment you can report this by:

You can also obtain a self-reporting form available from:

  • Stoke-on-Trent Citizen's Advice Bureau,
    Advice House,
    Cheapside,
    Hanley,
    Stoke-on-Trent
    ST1 1HL
    phone:01782 408600
  • North Staffordshire Racial Equality Council
    Equality House,
    75-77 Raymond Street,
    Hanley,
    Stoke-on-Trent
    ST1 4DP
    Phone:01782-407930
    Email:nsrec@btconnect.com

Self-reporting forms are also available at police stations, libraries, health centres, housing and social service offices and from some faith communities such as mosques, gurdwaras and African-Caribbean associations.

Alternatively you can report a racist incident online by filling in this form.

Information received will be treated in the strictest confidence.
SECTION A: Details of Victim
Name  Telephone
Address
Postcode
Email
Age Group
Under 16   16 - 24   25 - 34   35 - 44   44 - 55   Over 55
Ethnic Origin (Tick as appropriate)
Black African Pakistani Chinese White
Black Caribbean Indian Bangladeshi Others



SECTION B: Brief description of incident(s) or action(s)
(Please indicate if other family members are affected)



SECTION C: Type of incident(s)
Tick more than one box if appropriate
Arson Verbal Abuse Assault Damage to property
Disputes Malicious Phone Calls Nuisance Hate Mail
Theft Harassment Threat Graffiti
Others:
Time of incident    Date of incident
Location (eg home, work, street, etc)
If previous incident(s) have occurred please tick the box



SECTION D: Details of Perpetrators
Name (if known)   Telephone
Address (if known)   Postcode
Gender
Male Female  
Age Group
Under 16   16 - 24   25 - 34   35 - 44   44 - 55   Over 55



SECTION E: If this report is not being made by the victim, please complete this section
Name   Telephone
Address   Postcode



SECTION F: Have you reported this incident to any other agency
Yes    No
If yes, please indicate which agency below
Citizens Advice Bureau Police Local Authority
Victim Support Housing Associations REC
Others (Please state who)



AUTHORISATION
I authorise my complaint to be disclosed to other agencies indicated below
Citizens Advice Bureau Police Local Authority  
Victim Support Housing Associations REC All
Others (Please state who)