Make an ASB report Are you a former Longhurst Group customer or a Grand Union customer? * Longhurst Group Grand Union Thank you Please note: former Grand Union customers are required to complete this ASB form. You can report an antisocial behaviour incident here. Your details First name * Surname * Street address and house number * Postode Email address Telephone number Please provide your phone number, so we can contact you if needed. Preferred method of contact Phone Email Post Are you an Amplius customer Yes No Details of the incident Where did the incident happen? Address or location of where the incident occurred When did the incident happen? Please enter date and time Who was involved in the incident? Please give name and address, or a description and any distinguishing features What happened? Please tell us exactly what you saw or heard How did this incident affect you? Please tell us the way the incident has made you feel, include its effect on the people you live with, eg has it stopped you sleeping? Has it frightened your children? Witnesses Were there any independent witnesses? Yes No Reporting to agencies Have you reported it to the police? Yes No Have you reported it to the local authority? Yes No Have you reported it to any other agency? Yes No Upload relevant images Upload diary sheets Further details We would like to make contact with the person/s identified above to make them aware of the reported behaviour and give them an opportunity to comment about the allegations and where appropriate, give them a chance to change their behaviour. * I am happy for you to contact the person/s identified as responsible for the antisocial behaviour Yes No I am happy for you to disclose my identity to the person/s identified as responsible for the antisocial behaviour * Please be aware, if you choose No, Amplius will not reveal your identity to the perpetrator. We will still need to contact you for details of the incident and to record any future incidents. Not disclosing your identity may limit our ability to investigate your report or agree any form of action. While we will not disclose your identity if you do not want us to, we cannot stop people from making assumptions Yes No I am happy for you to discuss my report with other partner agencies * To help us deal effectively with ASB we work closely with other partner agencies such as the police, local authority and Youth Offending Teams etc. Yes No Please be aware that where we have a duty to pass information to a statutory agency such as the police or Social Services, such as where a child is at risk, we will be speaking directly to the relevant agency giving full details of the situation. Please tick to confirm you have read and understood this I confirm I confirm the details I have completed in this form are accurate and true to the best of my knowledge and belief Please tick box to confirm I confirm Would you like to receive a copy of your submitted information by email? To receive the information you must include a valid email address in the box above Yes No Communicating with you Would you like to receive information in an accessible format (eg braille, audio)? Yes No Captcha
