1Report details 2Incident details 3Summary Progress Report details Your report I am submitting this report on behalf of Myself Someone else Please indicate the circumstances of your request A complaint made to Liverpool City Council, Merseyside Police and/or a Registered Housing Provider (social landlord) once about an incident or crime motivated by hate (hate incident/crime) in the last 6 months A complaint made to Liverpool City Council, Merseyside Police and/or a Registered Housing Provider (social landlord) three times about separate incidents in the last six months Your contact details Name Email address About the person affected Name Address Postcode Find Address Loading addresses... Select Address -- Please select -- Address line 1 Address line 2 (optional) City Postcode Clear postcode/address Use the Lookup Postcode button to find the address.If you cannot find the address, please enter it manually Daytime telephone number Email address Gender -- Please Select -- Male Female Transgender Non binary Non-conforming Prefer not to say Sexual orientation -- Please Select -- Straight Gay Lesbian Bisexual Other Prefer not to say Ethnic origin -- Please Select -- Asian/Asian British - Bangladeshi Asian/Asian British - Indian Asian/Asian British - Pakistani Asian/Asian British - Any other Black/Black British - African Black/Black British - Caribbean Black/Black British - Any other Mixed - White and Asian Mixed - White and Black African Mixed - White and Black Caribbean Mixed - Any other mixed background White - British White - Gypsy/Roma White - Irish White - Traveller of Irish Heritage White - Any other white background Any Other Ethnic Group Prefer not to say Are you (or the individual you are submitting this report on behalf of) disabled? Yes No Prefer not to say Details of disability Religion (optional) Occupation (optional) Are you (or the individual you are submitting this report on behalf of) living in a Registered Provider of Social Housing Property (Housing Association)? Yes No Name of housing provider and how long you/they have been a tenant at the property Do you (or the individual you are submitting this report on behalf of) give consent for the housing provider to be made aware of the community trigger? Yes No Name of the organisation you would like to be reviewed for the community trigger About the other individuals who have submitted complaints Name of individual 1 Address of individual 1 Postcode Find Address Loading addresses... Select Address -- Please select -- Address line 1 Address line 2 (optional) City Postcode Clear postcode/address Use the Lookup Postcode button to find the address.If you cannot find the address, please enter it manually Daytime telephone number of individual 1 Email address of individual 1 Name of individual 2 Address of individual 2 Postcode Find Address Loading addresses... Select Address -- Please select -- Address line 1 Address line 2 (optional) City Postcode Clear postcode/address Use the Lookup Postcode button to find the address.If you cannot find the address, please enter it manually Daytime telephone number of individual 2 Email address of individual 2 Name of individual 3 Address of individual 3 Postcode Find Address Loading addresses... Select Address -- Please select -- Address line 1 Address line 2 (optional) City Postcode Clear postcode/address Use the Lookup Postcode button to find the address.If you cannot find the address, please enter it manually Daytime telephone number of individual 3 Email address of individual 3 Name of individual 4 Address of individual 4 Postcode Find Address Loading addresses... Select Address -- Please select -- Address line 1 Address line 2 (optional) City Postcode Clear postcode/address Use the Lookup Postcode button to find the address.If you cannot find the address, please enter it manually Daytime telephone number of individual 4 Email address of individual 4 No information is required, please proceed to the next page. Incident details 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. No information is required, please proceed to the next page. 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 Loading form summary...