PREJUDICE INCIDENT REPORTING FORM

(To be used for recording and monitoring any PrejudiceIncident relating to Age/ Disability/ Race/Religion or Belief /SexualOrientation/Sex (Gender)/Pregnancy and Maternity/ Marriage and Civil Partnership/Gender reassignment)

Definition: “A prejudice incident is any discriminatory act against an individual which occurs as a result of that person having one of the nine protected characteristics under the Equality Act 2010?”

Receiving Agency:
Reference No: / Date Reported to Agency:

1)Please indicate the Category of Prejudice Incident:See note (a)

Age / Gender reassignment / Religion or Belief
Disability / Race (including Gypsy/Traveller) / Sexual Orientation
Sex
(gender) / Pregnancy & maternity / Marriage & civil partnership

2)Location of the incident:

Location description: (b)
Area where incident took place:(c)
3)When did the incident happen? / Time: / on / (dd/mm/yy)

4)Give Brief Details of what happened: (d)

INSTRUCTIONS FOR COMPLETION

When you have completed the form then:

  1. Pass the form via your departmental manager for onward transmission to the Equalities Team (analytical and data recording only at this stage). Please send either via email th PIRF in the subject line or by post to Equalities Team, Aberdeenshire Council, Business Services, Customer Communication & Improvement, Woodhill House, Westburn Road, Aberdeen, AB16 5GB.Please mark the envelope private and confidential.
  2. Where the victim wishes to be referred to other agencies for support, please fill in section 10. Note: where there has been long term and persistent discrimination, the support of other agencies, case conferencing and counselling has proved invaluable.

Notes:

(a) One or more categories can be selected.

(b) A typical location might be a playground or a house or a doctor’s surgery or a pub or a church yard or a garage or a footpath or a street, etc.

(c) Please record the town or village or district or settlement or neighbourhood. NB Please do not include actual address.

(d)A typical description might be “Three unidentified persons, a female and two males, were causing a disturbance by shouting and swearing and using racially offensive language.” NB Please do not include names of victims or perpetrators.

(e)An incident can have more than one victim and/or perpetrator in which case please add sheets with details of additional victims and perpetrators.

(f)No additional information is required for age related incidents as this is covered by the victim statistical information.

(g)Options are English or Irish or Scottish.

(h) For example: Ghanaian, Nigerian, Tanzanian

(i)For example: Atheist, Buddhist, Christian, Hindu, Jewish, Muslim

(j)For example: council housing or housing association

Victim Details(e)

5)Victim Statistical Information / Age (years): / Gender:

Please complete the section(s) below according to the category of the incident:(f)

if DISABILITY related

Disfigurement / Mental Illness
Eyesight / Mobility
Hearing / Speech
Learning Disabilities / Other
(specify):
if GENDER related / Female / Male
Are you thinking about, in the process of, or have you completed the process of transitioning from one gender to another?' / Yes / No / Prefer not to say

If PREGNANCY/MATERNITY related

Are you pregnant? / Yes / No
Have you given birth within the last 6 months? / Yes / No

if RACE related (self-defined)

Scottish: / Indian:
English: / Bangladeshi:
Other British (specify): / Chinese:
Irish: / Other Asian (specify):
Gypsy/Traveller (specify): (g) / African (specify): (h)
Polish: / Caribbean:
Other European (specify): / Arab:
Multiple Ethnic Origin (specify): / Other ethnic origin (specify):
Pakistani: / Unknown:
if RELIGION/BELIEF related (self-defined) - specify:(i)

if SEXUAL ORIENTATION related

Bisexual / Heterosexual / Not stated
Gay / Lesbian / Unknown

If MARRIAGE OR CIVIL PARTNERSHIP related

Are you / have you ever been married / Yes / No
Are you / have you ever been in a same sex partnership / Yes / No

Perpetrator Details (e)

6) Perpetrator Statistical Info (if known) / Age (years): / Gender:

if RACE related (self-defined)

Scottish: / Indian:
English: / Bangladeshi:
Other British (specify): / Chinese:
Irish: / Other Asian (specify):
Gypsy/Traveller (specify): (g) / African (specify): (h)
Polish: / Caribbean:
Other European (specify): / Arab:
Multiple Ethnic Origin (specify): / Other ethnic origin (specify):
Pakistani: / Unknown:
if RELIGION/BELIEF related (self-defined) - specify:
7) Does victim want to be referred to another Agency? / Yes / No
Education Departments / Police / Social Work
Victim Support
Housing (specify) (j)
Other (specify)
8) Is a Multi-Agency Case Conference required? / Yes / No
9) Person completing this report: / Date:
Contact details:

Data Protection Declaration

By signing this, I agree that the information provided by me on this form may be shared with the organisations listed for the purpose of processing the Prejudice Incident Reporting Form, identifying repeat victims and for support and assistance(k)(l).

Signature of Victim/Informant:
Print Name:
Signature of Parent or Guardian:
Print Name:
Date:

Data Protection Information (m)

10)Details of Victim/Informant

Victim: / Informant (if not victim):

If reported by a witness and the victim has been identified, then please also complete an additional victim details form which can be accessed at the bottom of this page.

First name: / Tel No:
Surname: / Mobile No:
Date of birth: / No/Name (n) :
Place of birth: / Street:
Occupation: / Town:
Nationality: / Area:
Email: / Postcode:
Current School (if appropriate):

INSTRUCTIONS FOR COMPLETION

Data Protection Act 1998

  1. The Victim/Informant must be asked explicit consent for a referral to take place. This can be done in person or by other means (telephone, etc). If required, they must also be offered the opportunity to utilise the Language Line Service or an Interpreter to ensure understanding. The information contained in this form will be held confidentially, on computer, and used to tackle prejudice-related incidents.
  2. A partnership approach is often the best way to resolve prejudice-related incidents. The agencies specified have been identified as suitable for providing assistance and support to you, in regard to this case.

Notes:

(k)Your information will be processed fairly and lawfully and in accordance with the principles of the Data Protection Act 1998.

(l)The organisation to whom you are referred will inform you of name of their DataController and DataProtection Officer for the purposes of processing your personal information. You have a right to obtain details of the personal information the Data Controller holds about you. Such a request is known as a Subject Access Request and should be made in writing to the Data Protection Officer of the organisation to whom you are referred.

(m)This part of the form MUST NOT be forwarded to other agencies, unless express consent has been given under the Data Protection Declaration.

(n)Number or name of house.

DRAFT PIRF 130305