HLS1
NUISANCE/ HARASSMENT REPORT FORM
Housing Reference Number
Date of Report
Complainant's Name
Title
Forename
Surname
Complainant's Address
Postcode
Indicent Type(Tick all those appropriate)
Alcohol related
Criminal behaviuor
Drugs/ substances/ misuse/ dealing
Garden nuisance
Hate related incidents
Litter/ rubbish/ fly tipping
Misuse of public space/ communal areas or loitering
Noise
Nuisance from vehicles
Pets and animals nuisance
Physical violence
Vandalism and damage to property
Verbal abuse/ harassment/ intimidation/ threatening behaviour
Date of incident which has prompted complaint?
Date of incident
Time on 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
History
Have there been any previous incidents?Yes No
If yes, how many
Details of any previous incidents. This should include any other information which may be relevant to the case.
Alleged perpetrator/s
How many perpetrators are there1 2 3 4 5 6 Unknown
Details of alleged perpetrator
NameAddressAge (approx)Tenure (if known)
Details of witness
NameAddressTel numberAre they prepared to be contacted
Yes No
Yes No
Yes No
Police
Was the most recent incident reported to the police?Yes No
If yes,When was it reported?
What is the crime ref. number?
What has be done
If no,Why did you not report it?
Declaration
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.
Date
What level has this case been graded at? 1 2 3
Ethnic Origin of complainant.
AF African AA Asian African OE Other European
AI Asian Indian AO Asian Other OC Other Countries
AP Asian Pakistani CW Caribbean/ West Indian WC Wgite & BLack Caribbean
AB Asian Bangladeshi BR British WA White & Black African
AC Asian Chinese IR Irish WS White & Asian
OM Any other mixed background
Approvals and Consents
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 ABOUTYes No
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. Yes No
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.Yes No
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.Yes No