Uniting Staffordshire Against Hate Self Reporting Form

Please select one of the following characteristics, to help us understand why you were targeted: Please select one of the following characteristics, to help us understand why you were targeted: race (or perceived race) religion (or perceived religion) sexual orientation (or perceived sexual orientation) disability (or perceived disability) transgender identity (or perceived transgender identity)

Would you like to receive support or just tell us about the incident (please select all of the options below that apply to you): Would you like to receive support or just tell us about the incident (please select all of the options below that apply to you): I would like someone to contact me I would like to report the incident to USAH only I have reported the incident to the police

Name

Address

Email Address

Telephone:

How would you like us to contact you? How would you like us to contact you? telephone email

Do you have a preference when you'd like us to contact you? (please state)

Which area did the indicent happen? (please select an option below): Which area did the indicent happen? (please select an option below): Newcastle-under-Lyme Stoke-on-Trent Tamworth Borough Lichfield District Staffordshire Moorlands South Staffordshire Cannock Chase East Staffordshire Stafford Borough

Brief details of what happened (optional)