Report a Hate Crime

This form is designed to help the police and other agencies respond to crimes or incidents which are perceived to be motivated by hate or prejudice. Any information provided by you will be treated in strict confidence. The information you provide will be placed on computer and protected by provisions of the Data Protection Act 1998.

 

Hate Crime Reporting Form
Form Completed by: (optional)
Reporting Agency / Group Contact Details:
Details of the incident / crime
What type of incident / crime is being reported?
Time of incident:
Date of incident:
Please try to give as much information as possible.
Where did the incident take place? (i.e. town, area, street name, venue, landmark).
Describe what happened:
Where you injured or hurt?	Yes No
If yes, describe your injuries:
Were you treated at hospital or seen by a doctor?	Yes No
If yes, give details of staff seen, where, time and date of treatment
Was the incident witnessed?	Yes No
If Yes, by whom?
Was property damaged or stolem?	Yes No
If yes, give details including estimated value
Do you feel that the incident was motivated by hatred or prejudice?	Yes No
If yes, give details of what indicated this
Have you reported this indident to any other agency or group?	Yes No
If yes, identify the agency or group
Information about person(s) responsible:
Number of people involved:	1 2 3 4 5+
Description of offenders
Your Details:
Date of Birth:
Gender:	Male Female
Sexual Orientation:	Bisexual Gay/Lesbian Hetrosexual Prefer not to say
Ethnicity:	White British White Irish Any other white background White & Black Caribbean White & Black African White & Asian Any other mixed background Indian Pakistani Bangladeshi Black Caribbean Black African Any other black background Chinese Any other ethnic group Prefer not to say
Religion:	Buddhist Christian Hindu Jewish Muslim Rastafarian Sikh Other No Religion Prefer not to say
Spoken Language:
Nationality:
Disability:
County:
Any additional information:
Further (optional) personal details:
You can report this crime/incident anonymously if you wish. North Wales Police will record the incident and attempt to stop similar incidents happening in the future. If you would like the police to contact you about the incident reported, please provide the following contact information.
Note: The information you give will be treated in the strictest of confidence.
Your Fullname:
Your Full address:
Contact telephone no:
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