Section 1
Date of Incident

Street / Road / District*


Section 2

Name of Politician/Person*

Political Party or Supporter Complained About

Type of Incident
Violence & intimidationRisk/Damage to Private/Public PropertyConfrontationUnacceptable Public UtterancesBarriers to Access (Movement)Defacing of Buildings or InstallationsPolitical TribalismOther

Summary of Incident
(Who, What, Where, When, How)

Note: It is not mandatory to provide the following information
Section 3

Contact Number For Person Complained About in Section 2

Complainant's Name

Complainant's Telephone

Complainant's Email

Complainant's Gender
I am under 18 Years Old