About BHCDS
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Contact
Report a Hate Crime
About BHCDS
Resources
Contact
Report a Hate Crime
I’m the Victim
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Your Details
The following information relates to the person reporting the incident(s).
First Name
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Last Name
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Email
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Telephone
*
Address
*
Street Address
Address Line 2
City
ZIP / Postal Code
Contacting You
Does you speak English?
*
Yes
No
What language do you speak?
How should we contact you?
*
Email
Telephone
Postal Mail
Can we leave messages?
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Yes
No
Are there any restrictions on contacting you?
The Incident
Do you want support from BHC+DS?
*
Yes
No
What has happened?
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Arson and attempt
Assault
Attack on property
Bullying of children
Car damage
Discrimination
Graffiti
Mate crime
Ostracisation
Police discrimination
Rubbish nuisance
Theft or robbery
Threats
Verbal abuse
Written abuse
How many times has it happened?
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Once
More than once
When did it happen?
*
Where did it happen?
*
Incident Details
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Please enter details of the incident(s) and anything else you would like us to know.
Do you know the person who did it?
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Yes
No
Have you reported it to the police?
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Yes
No
Did they give you a crime reference number?
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Yes
No
Crime reference number(s)
Please enter any crime reference number(s) here:
About You
We need to take the following details to help record this incident and better support you. We also need it to monitor our services and ensure that we are reaching all communities. To ensure that we do not discriminate against anyone we ask the following questions.
What is your age?
*
Under 16
16-24
25-45
46-69
Over 70
Prefer not to answer
What is your gender?
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Male
Female
Non-binary / Gender Fluid
Prefer not to answer
Other
Is your gender identity different from that assigned at birth?
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Yes
No
Prefer not to answer
What is your sexual orientation?
*
Heterosexual/ Straight
Lesbian
Gay
Bisexual
Other
Prefer not to answer
Other
What is your ethnicity?
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White British
White Irish
Gypsy / Roma / Traveller
Eastern European
White other
Black African
Black Caribbean
Black Somali
Black other
Indian
Pakistani
Bangladeshi
Asian other
Dual Heritage White/Black Caribbean
Dual Heritage White/Black Afrian
Dual Heritage White/Asian
Dual Heritage other
Chinese
South East Asian other
Turkish
Kurdish
Middle Eastern other
Prefer not to answer
Other
What is your ethnicity?
*
White British
White Irish
Gypsy / Roma / Traveller
Eastern European
White other
Black African
Black Caribbean
Black Somali
Black other
Indian
Pakistani
Bangladeshi
Asian other
Dual Heritage White/Black Caribbean
Dual Heritage White/Black Afrian
Dual Heritage White/Asian
Dual Heritage other
Chinese
South East Asian other
Turkish
Kurdish
Middle Eastern other
Prefer not to answer
Other
What is your ethnicity?
*
White British
White Irish
Gypsy / Roma / Traveller
Eastern European
White other
Black African
Black Caribbean
Black Somali
Black other
Indian
Pakistani
Bangladeshi
Asian other
Dual Heritage White/Black Caribbean
Dual Heritage White/Black Afrian
Dual Heritage White/Asian
Dual Heritage other
Chinese
South East Asian other
Turkish
Kurdish
Middle Eastern other
Prefer not to answer
Other
Do you have a religion or belief?
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Buddhist
Christian denomination
Hindu
Islam
Jehovah’s Witness
Jewish
Pagan
Sikh
Spiritual
No religion
Prefer not to answer
Other
Do you consider yourself disabled?
*
Yes
No
Prefer not to answer
Please tick all that are appropriate
*
Deaf BSL user
Speech impairment
Hearing impairment
Visual impairment
Physical impairment
Learning difficulties
Autism Spectrum Disorder (ASD)
Mental or emotional distress
Long-term illness (over 12 months)
Prefer not to answer
Other
Please tick any that apply.
Your access needs
Do you have any access needs we should be aware of?
GDPR Disclaimer
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I have read and understand the
privacy policy
.