Report Online

For men aged 18 years & over in Essex

www.essexgaymen.org.uk Ansaphone 01245 250 256 Text 07949 348820

Please use this form to report a hate crime incident. Your personal details will remain anonymous unless you tell us otherwise. We comply with the Data Protection Act 1988.

Hate Crime on-line report form

What did the incident involve (tick as many that apply)

Please indicate if there was any loss of money or injuries:

1. THE INCIDENT

2. OFFENDER DETAILS

More about the offender(s)

3. A LITTLE ABOUT REPORTING

Please indicate if this incident has already been reported to the Police, Council or Housing Department

4. ABOUT THE VICTIM

Please tell us information about the victim or person making this report.

4. HOW YOU WOULD LIKE THE INFORMATION DEALT WITH

Please indicate with a ‘x’ how you would like the information provided shared.

Which local Borough or District do you live in?

Your Sexuality

Please indicate the type of hate crime you are reporting?

Verbal Abuse

Verbal Threat

Physical Assault

Sexual Assault

Robbery

Blackmail

Damage to Property

Damage_to_vehicle

Written Abuse e.g. text, email etc

Graffiti

Domestic Abuse

Police Behaviour

Other

Please describe the incident, giving as much detail as possible

Is this an isolated incident or an ongoing one?

Injuries

Loss of Money

Incident date (even if approximate)

Time of Incident

General Area Incident arose in

Location of Incident Location (please try to give as much information as possible e.g.: building, street, area)

How many offender(s) where there?

Are they known to you?

If you know them please tell us how (e.g: neighbour, partner etc)

If you are willing to give names and/or addresses of offender(s)do so here

Gender

Approximate Age(s)

Ethnic Appearance

Please give any further description (e.g. height, build and any distinguishing marks or features)

Was a vehicle used? If so please describe it (e.g. colour, make, model)

Your Religion

Your Gender

Age

Your Ethnicity

Other (specify):

A disability?

Are you the Victim

Reported to Police

reported to Council or Housing Dept

Reported elsewhere (other)

If reported to the Police, how do you feel about their involvement?

Crime Number or CAD ref (if you have one)

I would like to be contacted by Essex Gay Men and do NOT want my personal information passed on to anyone else at this stage.

I want my identity to remain anonymous but would like all the other information shared with the Police.

I would like all the information including my personal details passed to the Police

I would like all the information shared with suitable support agencies but not the Police

Name

Address

Phone

Mobile

Please indicate any specific contact requirement e.g. do not leave messages, only contact at certain times, please contact only by email