Please ensure you complete all questions highlighted in pink.
How did you hear of Galop? Please select Used before Word of mouth Poster or card Press advert Referred by another organisation Search engine Other Prefer not to say
Are you a Please select Victim Witness Third Party Prefer not to say
Is this incident Please select A one-off occurence Part of ongoing abuse Prefer not to say
What did the incident specifically involve (please tick as many as appropriate)
Verbal abuse (name calling/shouting out) Verbal threat (specific threat made) Physical assault (actual incident of violence) Attempted physical assault Sexual assault Rape Sexual abuse
Robbery Blackmail Damage to property/vehicle Written abuse (e.g.: Letter/Email/Text) Graffiti Unspecified domestic violence Problem with the Police Arrest/caution by the Police
Other (please specify)
Date of incident (if you don't know the exact date(s) please give approximate)
Time of day of the incident Please select Morning Afternoon Evening Late night Early hours Various Prefer not to say
If you know the specific time of the incident please tell us:
In which London borough did the incident take place Please select Barking & Dagenham Barnet Bexley Brent Bromley Camden City of London Croydon Ealing Enfield Greenwich Hackney Hammersmith & Fulham Haringey Harrow Havering Hillingdon Hounslow Islington Kensington & Chelsea Kingston upon Thames Lambeth Lewisham Merton Newham Redbridge Richmond upon Thames Southwark Sutton Tower Hamlets Waltham Forest Wandsworth Westminster Prefer not to say
Location (please try to give as much information as possible e.g.: building, street, area)
Please tell us about the incident in your own words, giving as much detail as possible
Were there any injuries? Please select Yes No Prefer not to say
If 'Yes' please give details
Was there any loss or damage to property or money? Please select Yes No Prefer not to say
If 'Yes' please give details, including its value
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It helps us to monitor hate crime if you can give as much detail as possible in this section although you do not have to if you do not wish to.
How many offenders were there? Please select 1 2 3 4 5 5+
Did you know them? Please select Unknown Known to me Known by sight/familiar Prefer not to say
If you know them please tell us how (e.g: neighbour, partner etc)
If you are willing to give us their names and/or addresses please do so here:
Please try to give a description:
Gender Please select Male Female Mixed group All Male group All Female group Prefer not to say
Approximate age(s)
Ethnic appearance
It is very useful if you can also give any further description (e.g. height, build and any distinguishing marks or features)
Was a vehicle used? If so please describe it (eg colour, make, model)
In order to help us deal with hate crime it is useful for us to know some details about you (or the victim if this is not you).
Which Borough do you live in? Please select Barking & Dagenham Barnet Bexley Brent Bromley Camden City of London Croydon Ealing Enfield Greenwich Hackney Hammersmith & Fulham Haringey Harrow Havering Hillingdon Hounslow Islington Kensington & Chelsea Kingston upon Thames Lambeth Lewisham Merton Newham Redbridge Richmond upon Thames Southwark Sutton Tower Hamlets Waltham Forest Wandsworth Westminster Outside London Don't Know Prefer not to say
Gender identity Please select Male Female Other Prefer not to say
We also provide services to trans people. Is your gender identity the same as you were assigned with at birth? Please select Yes No Prefer not to say
Age
Religion Please select Buddhist Christian Hindu Jewish Muslim None Other Prefer not to say
Sexuality Please select Gay Lesbian Bisexual Heterosexual Other Prefer not to say
Ethnic background
White British Irish Other
Mixed White & Black Caribbean White & Black African White & Asian Other Mixed background
Asian Asian or Asian British Indian Pakistani Bangladeshi Chinese Other Asian Background
Black Black or Black British Caribbean African Other Black Background
Other ethnic background (please specify)
Are you employed? Please select Full time Part time Full time education Part time education Unemployed Retired Prefer not to say
Do you have a disability? Please select Yes No Prefer not to say
Do you have a health problem? Please select Yes No Prefer not to say
Have you reported this incident to anyone else (please tick as many as apply)
Police Council or housing service Partner/Friend/Family member Other
If 'Other' please specify:
If you have reported it to the Police did you get a Crime Reference Number? Please select Yes No Prefer not to say
If 'Yes' please tell us what it is:
If you have reported to the Police how did you feel about their response?
If you have decided NOT to report to the police please tell us why you have decided not to:
The information you have provided will be anonymously logged by Galop to produce statistics that, where relevant, will be shared with other agencies to help prevent other incidents in the future.
However, if you want the police to investigate the incident, they will need to speak to you.
Please select one of the following options:
I would like to be contacted by a Galop caseworker, but do not want my contact details passed onto any other agencies (including the Police) I want the police to investigate and I want my contact details to be given to the police I wish to remain anonymous and do not want the police or Galop to contact me If you would like to be contacted by a Galop caseworker, or if you want the police to investigate the incident, please provide your contact details below: Your name Address: Postcode Home telephone Mobile Email If there are any restrictions you would like us to observe when we contact you please detail them here: (e.g. do not leave messages, only contact at certain times) If you have a disability which you would like us to be aware of when we contact you (e.g. hearing impaired, please contact only by email) please tell us here: If you have completed as much information as you can, please click the 'Submit' button below once.
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