When completing this form, please note that fields marked * have to be filled in.
MrMrsMissMsOther
If other, please specify
First name *
Surname *
Address for correspondence *
Postcode *
Telephone number *
Email address *
Local community area * Select... LCA1 - Brookfield LCA2 - North Ribbleton LCA3 - Moor Nook LCA4 - Fishwick LCA5 - South Ribbleton LCA6 - St Matthews LCA7 - Deepdale LCA8 - City Centre LCA9 - Ashton LCA10 - Ingol
Please state what you consider to be your ethnic origin:
White BritishWhite IrishWhite - otherBlack or Black British - AfricanBlack or Black British - CaribbeanBlack or Black British - otherAsian or Asian British - IndianAsian or Asian British - PakistaniAsian or Asian British - BangladeshAsian or Asian British - otherMixed White and Black AfricanMixed White and Black CaribbeanMixed White and AsianMixed - otherOther ethnic origin - ChineseOther ethnic origin - other groups
Please specify origin
MaleFemaleTransgender
Under 16 years6-24 years25-29 years30-34 years35-39 years40-44 years45-49 years50-54 years55-59 years60 years or over
Please explain the problem *
Where is it happening? Please be as specific as you can - for example, at a particularproperty, in a part of the street, or so on
Does the problem happen at a particular time of the day or week?
YesNo
Please state the time of day when this usually happens
DaytimeEveningNight-timeVaries
Please state the time of week when this usually happens
Monday to FridayWeekend
How often is it happening?
One-offEvery now and againOnce a weekTwo to three times a weekMore than three times a weekEvery day
Has this problem been reported to CGA before?
Who was it reported to?
When was it reported?
Do you consider this incident to be racial or homophobic harassment - threats tosomeone on race or sexuality grounds?