ASB Case Review - Northumbria PCC

Name(Required)

The name of the person experiencing ASB

Address(Required)

Street Address Address Line 2 City Postcode

The address of the person experiencing ASB

Date of Birth(Required)

The DOB of the person experiencing ASB

Contact number(Required)

The contact number of the person experiencing ASB

E-mail Address(Required)

The email address of the person experiencing ASB

Tenure(Required)

The type of property the person experiencing ASB lives in

Please specify the RSL

If you have selected ‘Registered Social Landlord’ (RSL), please specify the RSL

I prefer to be contacted by:(Required)

Preferences of the person experiencing ASB. Please note, that by selecting ‘Letter’ this may delay the time it takes to process your ASB Case Review request

Consent to Share information(Required)

Yes
No

Consent from the person experiencing ASB. The details you provide will not be passed to a third party without your consent. Please note that without your consent to share information, we are unable to process your request to activate a ASB Case Review.

Incidents

In order to meet the ASB Case Review threshold you must have reported 3 incidents of ASB in the last 6 months. For this reason, we require these details in this form.

We understand that you may have experienced more than 3 incidents of ASB, however, at this stage, we only need you to provide information for 3 incidents that you have reported. This will help us to assess whether or not the threshold is met.

We understand that you may not have all of the specific details, if this is the case, you are able to use approximate dates and information.

Where possible, please include incident or case reference numbers.

Please Note: This form should not be used to report new incidents of anti-social behaviour

Incident 1 - Date(Required)

If you cannot recall the exact date please use the approximate date

Incident 1 - Details(Required)

Incident 1 - Can you identify the person(s) responsible?(Required)

Please include an address and name where you can.

Incident 1 - Which agency did you report this incident to?(Required)

Incident 2 - Date(Required)

If you cannot recall the exact date please use the approximate date

Incident 2 - Details(Required)

Incident 2 - Can you identify the person(s) responsible?(Required)

Please include an address and name where you can.

Incident 2 - Which agency did you report this incident to?(Required)

Incident 3 - Date(Required)

If you cannot recall the exact date please use the approximate date

Incident 3 - Details(Required)

Incident 3 – Can you identify the person(s) responsible?(Required)

Please include an address and name where you can.

Incident 3 – Which agency did you report this incident to?(Required)

Is the anti-social behaviour ongoing (unresolved)?(Required)

How affected do you feel by what has happened?(Required)

Impact on the person experiencing ASB.

Do you feel that you are being targeted due to any of the protected characteristics listed below?(Required)

Protected characteristics include: Gender Reassignment, Marriage/Civil Partnership, Pregnancy/Maternity, Age, Religion/Belief, Race, Sexual Orientation, Gender or Disability

If you answered ‘yes’ to the above question, please select the protected characteristic:

Do you feel that there is a personal risk of harm to you or to people in your household?(Required)

Please note that the term ‘harm’ can mean harm to your physical or mental wellbeing

If you answered ‘yes’ to the above question, can you please explain where you feel there is a personal risk of harm?

If you require any reasonable adjustments throughout the ASB Case Review process, please detail these below:

Reasonable adjustments relate to specific requirements you may have to enable you to better access, engage with and understand this process

What is your sex?

Female
Male

Is the gender you identify with the same as your sex registered with at birth? If not, please state your gender identity, otherwise respond 'yes':

No
Yes

Your gender identity

How old are you?

What is your ethnic group?

Which of the options below best describe your employment status?

If you are raising this request on behalf of someone, please provide your contact details.

Please Note: If you are raising the request on behalf of someone else, we may still need to obtain consent from the named person before progressing this request.

Name

Job Title

Organisation

E-mail Address

Contact Number

I have consent to share this information

Phone

This field is for validation purposes and should be left unchanged.