Liverpool City Council

About the incident

Date the incident happened

Who did you (or the individual you are submitting this report on behalf of) report this incident to?

What is the name of the person you (or the individual you are submitting this report on behalf of) first reported it to or the reference number?

Details of the incident

What response did you (or the individual you are submitting this report on behalf of) get about the incident?

What is your (or the individual you are submitting this report on behalf of's) expected outcome of the review process?

About the separate incidents

Date the first incident happened?

Who was this incident reported to?

What is the name of the person it was first reported to, or the reference number?

Details of the first incident

What response was received in relation to this incident?

Date the second incident happened?

Who was this incident reported to?

What is the name of the person it was first reported to, or the reference number?

Details of the second incident

What response was received in relation to this incident?

Date the third incident happened?

Who was this incident reported to?

What is the name of the person it was first reported to, or the reference number?

Details of the third incident

What response was received in relation to this incident?

What is the expected outcome of the review process?

Further details

Would you (or the individual you are submitting this report on behalf of) agree to a visit from partner agencies in relation to their complaint?

Yes
No

Can you (or the individual you are submitting this report on behalf of) provide any photographic or video evidence to support the complaint(s)?

Yes
No

We will only consider complete recordings of the entire conversation, meeting or incident, not highlights or snippets. The time and date the recording was made should be included.

Please upload evidence - optional To upload multiple files, hold 'Ctrl' (Windows) or 'Cmd' (Mac) when selecting files to upload.

Consent

Confirmation

I confirm that the individual I have given details of, has given consent for their details to be shared on this form, used for the ASB Case Review and given consent for their information to be shared with relevant agencies if necessary.

Before you submit this form please review your answers below. If you need to change anything, use the 'previous' button on the bottom left to go back to a section. Then submit the form by selecting the 'Submit button' at the bottom of this page