Community Trigger Referral Form

Stevenage Borough Council

Community Trigger referral form

This is the Community Trigger referral form.In an emergency please contact the relevant emergency service, police, fire or ambulance on 999.

Please complete this form as fully as possible.All information is treated in the strictest confidence. However, we may share information with our partner agencies in order to provide a solution to your problem.Your case may be passed to an appropriate lead agency who will respond to you such as the police, your housing provider or environmental health team.

If you would prefer to contact us by telephone to discuss your situation or to check on the progress of your Community Triggerreferral please contact the Anti-Social Behaviour Team on 01438 242666

About your situation

Have you reported this beforeYes / No

Who did you report it to? ......

Have you reported this incident to another agency or council team?Yes / No

Please tell us here, including any reference, name of officer or team and crime or reference numbers you were given.

......

Does this issue affect more than one household or business premise?Yes / No

Please provide as much detail as possible, including relevant names and addresses

......

Do you think the incidents/concerns could be described as one or more of these?

Hate incidents / crimes

Anti-social behaviour

Neither of the above

Can you confirm that (as far as you know) no action has been taken

Yes

Don’t know / Unsure

Where did the incident/problem take place?

Please provide as much detail as possible, including any relevant or nearby addresses

......

What happened?

Please describe your concerns and what has happened

......

Has anyone else witnessed this?

Please give the names of any witnesses to the incidents/problems

......

How are the incidents affecting you?

Please state how the problem/concern has made you and your household feel. Note any affects (for example: how at risk you feel, how the situation is affecting your health, if you have changed your daily routine as a result of the situation.

......

Do you think the incidents / concerns are because of:

Ethnicity

Religion or faith

Disability

Sexual orientation

Being transgendered

None of the above

Your contact details

Please provide your details so that we can contact you. If you are completing this form on behalf of a friend or a client of your service, please provide details of the person affected by this situation. We will use this to ask any further questions or provide feedback on your referral as necessary.

Name: ......

Address:......

......

...... Postcode: ......

Telephone: ...... Email: ......

Which of these best describes you?

Council tenant (include leasehold)

Private tenant

Owner occupier

Housing Association

Other

Please provide us with your landlord's name or the name of your contact officer

Equalities monitoring (optional questions)

Gender

Male

Female

Transgender

Age

Sexual orientation

Heterosexual

Homosexual

Bi-sexual

Other: ......

Religion - please state

......

Please give details of any disability

Ethnicity

White British

Bangladeshi

Black African

Black Caribbean

Black other

Chinese

Indian

Irish

Mixed other

Mixed White Asian

Mixed White African

Mixed White Caribbean

Other Asian

Pakistani

Irish Traveller / Gypsy

White Other

Prefer not to say

Keeping you informed

We will keep you informed about progress.

Our promise is to acknowledge receipt of your referral immediately.

An initial assessment of your situation will be carried out within one working day and you will be contacted.

If your referral meets the criteria an officer from an appropriate lead agency (in discussion with you) will review your situation and agree appropriate actions with you within five working days.

Do you wish to be informed about the progress of your referral

Yes, please keep me informed

No, I do not wish to be kept informed

Your feedback

Please tell us how easy you found this form to use and if the information about Community Trigger was helpful

Declaration

I confirm that the information given in the above form is correct to the best of my knowledge.

Signed: ...... Date: ......