Fields including (*) are mandatory and must be completed.

      Hatred Motivation
 What was the Motive behind the Incident ?   *
  
      Are you the Victim or the Witness
 I am the ?   *
  Victim    Witness    Other
 If you selected "Other" - please specify:   *
 
      The Incident
Describe the incident in your own words, including why you perceive this to be a hate related incident.
Please give as much detail as possible:   *
 
 When did the incident take place (be as specific as possible) ?   *
  Incident Date : : :
  Incident Time : : :
 Where did the incident take place ?   *
 
 Were you or the victim injured ?   *
  Yes    No    Unsure
 If you selected "Yes" - please specify:   *
 
 
 Did any loss or damage to property result from the incident ?   *
  Yes    No    Unsure
 If you selected "Yes" - please specify:   *
 
      Witness Details
 Were there any witnesses ?   *
  Yes    No    Unsure
 If you selected "Yes" - please specify:   *
 
      Offenders Details
 (Confidential - For use only by PSNI)
 How many offenders were there ?   *
  1   2   3   4   5   More Than 5   Unsure  
 Do you know them ?   *
  Yes    No
 Can you name them ?   *
  Yes    No
 If you selected "Yes" - please provide Names and if possible, addresses:
 
 Can you describe the offenders ?
 
 Actual or perceived ethnicity ?   *
 
 If you selected "Other" - please specify ethnicity:
 
      Vehicle Details
 Did they have a vehicle ?
   Yes    No    Unsure
 If you selected "Yes" - can you describe the vehicle:
 
 Can you identify the following ?
  Vehicle Make:   Vehicle Colour:
   
  Vehicle Model:   Registration Number:
   
      Personal Details
 (Confidential - For use only by PSNI)
 What is your Gender ?
  Male    Female
 What is your Ethnicity ?   *
 
 If you selected "Other" - please specify ethnicity:
 
 
 Would you like to be contacted by the Minority Liaison Officer ?   *
  Yes    No
If you have requested to be contacted by the Minority Liaison Officer, please insert into the appropriate fields below:
(1.) Contact Name.
(2.) A Contact Address or Contact Telephone Number.
The Police Service of Northern Ireland will record the above incident. If you do not provide the information requested, the Police will not be able to fully investigate this incident, prosecute the offender (where a crime has occurred) or prevent further similar incidents taking place.

Any information provided will be dealt with in a Sensitive and Confidential manner and in accordance with Data Protection Legislation.
  Name:   Daytime Phone Number:
   
  Address:   Evening Phone Number:
   
  City / Town:   Mobile Phone Number:
   
  Email Address (If Possible):   Date of Birth:
    : :