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Housing Reference Number
Date of Report
Indicent Type(Tick all those appropriate)
Date of incident which has prompted complaint?
Date of incident
Time of incident
Place of incident
Details of this incident(Record words spoken, physical actions etc.)
What effect has the incident had on you? I.e. fear of leaving home, giong to certain areas
Have there been any previous incidents?
If yes, how many
Details of any previous incidents. This should include any other information which may be relevant to the case.
How many perpetrators are there
Details of alleged perpetrator
Tenure (if known)
Was the most recent incident reported to the police?
If yes, When was it reported?
What is the crime ref. number?
What has be done
If no, Why did you not report it?
I understand that the information I provide on this form may be used in legal action. Therefore, I confirm that the information given is to my knowledge true.
What level has this case been graded at?
In order for the Council to take certain action we need your approval and consent.
1. CONSENT FOR INTERVIEW WITH ALLEGED PERPETRATOR
The Council has a policy of taking action to prevent anti-social behaviour. The first stage is to interview the person(s) you have made a complaint about.
I AGREE TO THE COUNCIL INTERVIEWING THE PERSON I HAVE COMPLAINED ABOUT
2. CONSENT FOR ACTION AGAINST ALLEGED PERPETRATOR
Following the interview with the person you have complained about, The Council may decide to take action against the perpetrator of nuisance and harassment and will need your assistance. The first step is to discuss the complaint with a Housing Officer.
I AGREE TO THE COUNCIL TAKING ALL APPRORIATE AND RELEVANT ACTION AGAINST THE PERSON I HAVE COMPLAINED ABOUT.
3. POLICE CONSENT
In order to progress your case it may be necessary to contact the police to obtain further information or confirm information already provided.
I AUTHORISE BOURNEMOUTH BOROUGH COUNCIL TO CONTACT THE POLICE TO OBTAIN INFORMATION THAT WILL BE OF ASSISTANCE IN DEALING WITH MY CASE.
4. MEDICAL CONSENT
It may be necessary for the council to gain information from your GP relating to one or more of the incidents you have reported. The information requested will only be used to support your case and for no other purpose. Please confirm that you are happy for this information to be obtained.
I AUTHORISE BOURNEMOUTH BOROUGH COUNCIL TO CONTACT MY GP TO SEEK ANY INFORMATION HELD ABOUT ME WHICH COULD BE RELEVANT TO THIS CASE.
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