Isle of Wight Council

Reporting diversity incidents

CONTACT DETAILS

*	How would you like this report dealt with?	Formally investigated No further action taken
	Please tick here if you prefer not to give your name	NB: We can not carry out an investigation unless you state your name but this will be logged as an incident.

	Title
	Forename
	Middle name/Initials
	Surname

Please tick here if you prefer not to give your contact details

	Building/house name/number
	Street address
	Town name
	County
	Postcode
	Telephone number (include area code)
	Email address
	Fax
	Preferred method of contact	Home number Mobile number Work number email Fax Post prefer not to say

ABOUT THE INCIDENT

Are you?

Victim Witness Third Party

	*If reporting as a witness or third party, if possible please include your contact details or contact details of the individual involved

What was the nature of the incident? (tick all that apply)

racism religion disability homophobia (sexual orientation) transphobia (transgender) ageism gender bullying other

	Describe the incident in your own words, give as much detail as possible.

	Have you reported this to anyone else?	Yes No
	If yes, who did you report it to, when was it reported

For all communications regarding this form please quote the following reference information

	Reference number:
	Date of submission:

Date printed: 07/03/2013