Amaze Equality, Diversity and Inclusion

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Amaze Equality, Diversity and Inclusion – Incident Form

Please complete this form if you feel you have experienced discrimination, abuse or microaggressions when accessing support from - or working at - Amaze. This may have been related to race, ethnicity, religion, belief, disability, sex or gender, sexual orientation, age, marriage and civil partnership, pregnancy and maternity, or being trans or non-binary.

If you have experienced these things when accessing any other service, we strongly encourage you to report this to that particular service directly. However, if you don’t feel comfortable doing this, you can complete our form and we will report it on your behalf.

Did this incident happen at Amaze? *

Yes

If no, which service/organisation did it happen at?

If it was at Amaze, which service were you accessing, or trying to access? (Or if you are an employee or volunteer with Amaze and this happened at work, which team was involved?)

Date of incident

YYYY

Time of incident

Time

What does the incident relate to? (Tick all that apply) *

Race or ethnicity

Religion or belief

Sex or gender

Trans or non-binary

Age

Sexual orientation

Disability

Marriage and civil partnership

Pregnancy and maternity

Other:

Required

What happened? (Tick all that apply) *

Verbal abuse or offensive language

Threats

Malicious communications (phone calls / texts / emails / social media)

Physical assault

Sexual harassment / sexual assault

Other:

Required

Incident details

In order to enable us to respond to your enquiry without having to contact you for more information, please be as specific as possible with the information that you supply.

Please give details of exactly what happened during the incident *

Have you experienced this type of incident at Amaze before? (Or if you are reporting an incident that happened at a different service, have you experienced this type of incident at that service before?

Yes

Clear selection

If yes, please tell us how many times

Less than 3 times in the last 6 months

3 times or more in the last 6 months

Clear selection

Your details

If we need more information, is it okay to contact you? If so, please provide your details below.

Giving us your details also means we can let you know what we have done with your incident report.

Please note, if we cannot contact you for further information, this may limit our ability to investigate this incident, and prevent future recurrences.

Name

How would you like to be contacted?

Phone

Clear selection

Telephone

Were there any witnesses to the incident?

Yes

Clear selection

If yes, please provide details of any witnesses

Is there anything else you'd like to add?

If you are reporting an incident with a different organisation/service, are you happy for us to share with them the information you've provided here *

Yes

n/a (I am reporting an incident at Amaze)

What happens next?

Thank you for completing this form. This will go straight to our Chief Executive who will arrange a full review of the incident, and identify necessary actions and learning. Any incidents received will also be taken to our Board’s Personnel Subgroup for review. If you have provided contact details we will update you with our progress.

Submit

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