Walksafe Incident Report Form, Queensland Australia:
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The Online Report information will be discussed with the Queensland Police Service, however no personal details will be shared without your consent

This Walksafe Incident Report is not an official Queensland Police Criminal Report, please contact your nearest police station to complete a crime report.

  • Have you experienced hate-related harassment, property damage or violence?
  • Do you have personal knowledge of hate-related harassment, property damage or violence?
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    INFORMATION ABOUT THE INCIDENT
    Please Select if you are:

    		If other please specify: Time of incident:
    Date of incident:
    (dd/mm/yy)    		 Suburb Name / Postcode of incident: Location:


    If other, please specify:
    Please tick the box/es that applies to your experience: Verbal Abuse
    Harrassment such as spitting, offensive gestures, being followed
    You were hit, beaten or physical attacked
    You were raped or sexually assaulted
    Your property was purposely damaged, stolen or vandalised
    Someone tried to hit you, but they were stopped or you got away
    Someone tried to rape or sexually assault you, but they were stopped or you got away
    Someone tried to damage or vandalise your property, but they were stopped or you got away
    If Yes, please specify:
    Please tell us more about the person involved, or if you are the person involved, please tell us more about yourself.
    Age: City/Town: Postcode:
    Gender Identity:

    If other, please specify:
    		 Sexual Identity: Ethnicity:

    If other, please specify:
    Did yourself or the person suffer any physical injuries? No Yes If yes, please describe:
    Was the main motivation:
    Sexual Identity No Yes If Yes, please specify:
    Gender Identity No Yes If Yes, please specify
    Racial No Yes If Yes, please specify
    Disability No Yes If Yes, please specify
    Religion No Yes If Yes, please specify
    Was the offender acting alone or part of a group?
    Alone Gender Identity of Offender :

    If other, please specify:
    		   Age of Offender: Relationship to Offender:

    If other, please specify:
    Sexual Identity of Offender:   Ethnicity:

    If other ethnicity, please specify:
    Group How many?


    		 Please give some information in relation to the group
    (ie Gender, Average Age, Relationship, Sexuality, Religion, Ethnicity)
    Unsure
    Please tell us in your own words what happened?
     
    Police
    Have you contacted the Police? Yes No
    Was a Police Crime Report Completed? Yes No
    Was this incident reported to anyone? Yes No If yes, please select who:

    If Other, please specify:
    While we may be able to provide you with information, referrals and assistance, we cannot guarantee you an IMMEDIATE response,
    although we do promise to get back to you as quickly as possible.
    You may remain anonymous and do not have to give us any information that would reveal your identity. However, if you would like more information about hate crimes or require our assistance in some way, please complete the following so we can contact you:
    Would you like us to contact you about this incident?
      Yes No
    If Yes, please complete:
    Name:
    Address:
    Postcode:
    Telephone Number:
    Mobile Number:
    Email Address:
    Preferred Contact:
    To send this report, please click the submit button below.