Incident Report Form | You Can Trust Us

Your Story

If you have experienced or witnessed incidences of racism, we would like to hear from you so that we can advocate for change in appropriate venues.

Personal Details - Optional
First Name		Enter in your first name.
Surname		Enter in your surname.
Email*		Use a valid email address.
Town / City		What Town are you from?
County		What County are you from?
Incident Details
Time of incident*		What time did it happen?
Date of incident*		Please use DD/MM/YY
Type of Incident		Pick one from the list.
If other, please state:		Please be concise.
Where did the incident occur?		Pick one from the list.
If other, please state		Please be concise.
Additional
Have you reported the incident?	Yes No	Have you reported this incident already?
Would you like an authority to report to?	Yes No	Contact the authorities?
Additional Comments		Anything else you want to add?

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