WARNING

If you are in immediate danger or the incident is ongoing

Who?*
Who did the incident happen to?
Why?*
I think it was motivated by:
*
I think it was related to:
Related to (Other)
Please explain what you think motivated the crime. If you don't know, please tell us that.
Now tell us when and where
When?*
The incident took place on:
Time*
at approximately:

HH :

MM
Where?*
Tell us where it happened. Please include as much information as possible.
In which local authority did it take place?*

Type of incident*
It was:
Injuries*
Was anyone injured?
Description of what happened*
Please provide as much (or as little) information about the incident as you can.
Almost done
It would be really helpful if you could provide a bit more information about the victim and the offender. If you are short on time, you can jump to the last part of the form.
Could you spare a couple more minutes?*

That's great. Thank you
About the victim
Please answer a few more questions about the victim to give us as much information as you can. If you don't know the answer to some questions, just leave them blank.
Age
Select Age
Gender
Gender
Has the victim ever identified as any other gender?
How does the victim describe their gender?
Sexual, romantic or affectional identity or orientation
Orientation or identity
How does the victim describe their orientation or identity?
Other orientation or identity
Please specify
Ethnicity
Prefer not to say
You can either select the prefer not to say option here, or select from the choices below.
- Prefer not to say
White
Mixed / multiple ethnic groups
Asian / Asian British
Black / African / Caribbean / Black British
Other ethnic group
Other ethnicity
If you have selected other in any of the above, please specify here
Religion or Belief
Select Religion or belief
Religion or belied - other
Please specify
Impairment and Disability
Impairment
Does the victim have a physical or mental impairment that has a substantial and long term affect on their ability to carry out normal day-to-day activities?
Disability
Does the victim consider themselves to be disabled (for example, have they experienced disabling barriers, perceived or actual, such as people’s negative attitude towards them because of their impairment, the way things are organised, inaccessible buildings, outdoor environments or transport, the way information is communicated to them)?

About the offender(s)
Does the victim know them?
Please describe them
Please describe the offender(s) in as much detail as possible. You might consider their age, gender, ethnicity, sexual orientation etc if you know that information. You could also include things like height, build, clothing, distinguishing marks or characteristics.

Ready to report
Would you like us to report this to the local agency partnership?*
If you select yes, the information you have provided about the incident will also be sent to the Police. Umbrella Cymru will also receive a copy of the report and we can help you if you want us to. If you don't want to report it, ONLY we will receive the information and use it for monitoring the number of incidents only.
Police Force Area*
OK, we won't report it, but could we contact you if we need to?*
We will just keep the information to monitor the number of incidents. We might like to contact you to discuss, but you are welcome to report the information anonymously if you prefer.
Great, we'll just need some contact details.
Please tell us your:
Name*
First Last
Address*
Address Line 1 Address Line 2 Town County Post Code Country
Phone*
Email
Specific contact instructions
Please tell us if you would like to contact you in a specific way, at or during specific times, or any other instructions about how to contact we need to know.
Confirmation
Accept / Confirm*
By ticking the box below you confirm that the information provided is a true and accurate account of the incident to the best of your knowledge. If you have requested that we pass this information on, you are accepting that this information will be sent directly to us and the Police. The information you have provided will always be treated confidential.
- I Accept / Confirm
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