COMMUNITY TRIGGER
ASB Case Review Request Form (Please complete one form per victim)
SECTION ONE: Contact Details
Please provide us with your contact details; we need to be able to keep in contact with
the person who is requesting the case review. This will be the point of contact for all
correspondence throughout the case review process.
Your Name:
Organisation/group:
(if applicable)
Position in organisation/group:
(if applicable)
Your Contact Details: Address:
Email:
Telephone:
Are you the victim or
representing a victim(s)?
Victim: YES NO
Representing a victim: YES NO
Victim’s Name:
(if different to above)
Victim’s Address:
(if different to above)
If you are representing a victim(s), you must have signed consent to request a case review
SECTION TWO: Consent from victim
If you are the victim and requesting the case review, please sign the below declaration. If you are
acting on behalf of a victim involved in this case, please ask them to sign the below declaration before
submitting the case review request form. One form needs to be completed for each victim.
As a victim of the incident(s) indicated on this form, I give consent for the Local Delivery
Team to request information from relevant organisations including the local council, police,
health providers and housing associations about the case, and to share that information with
appropriate agencies for consideration at a case review meeting.”
Victim Name Signature Date
Even if consent is refused, the organisations may share information where required or
permitted under statutory provisions.
1
October 2014
SECTION THREE: Incident Information
Each incident must have been reported to one of the following organisations; North Yorkshire Police,
local authority or housing association. Each incident must have been reported within one month of it
occurring and must have taken place in the last six months. Please provide as much information
as possible.
INCIDENT ONE
Date and Time of
Incident:
Brief Details
including location:
Reported to: Name: (if known)
Organisation:
Incident or
Reference Number:
(if known)
Date and Time of
Report:
Method of reporting: Telephone: Email: Written: In person:
Action taken
by whom:
INCIDENT TWO
Date and Time of
Incident:
Brief Details
including location:
Reported to: Name: (if known)
Organisation:
Incident or
Reference Number:
(if known)
Date and Time of
Report:
Method of reporting: Telephone: Email: Written: In person:
Action taken
by whom:
2
October 2014
SECTION FOUR: Reason for requesting a case review
The more information you provide in this section, the better understanding the case review meeting will
have of the current situation and your expectations of solution.
What is the current situation?
Please could you explain why you are unhappy with the action that has been taken?
What would you like to see done to resolve the issue?
Are you currently receiving support from any agency in relation to these incidents?
Please provide details.
Any other information you would like to provide in relation to the incidents?
3
October 2014
INCIDENT THREE
Date and Time of
Incident:
Brief Details
including location:
Reported to: Name: (if known)
Organisation:
Incident or
Reference Number:
(if known)
Date and Time of
Report:
Method of reporting:
Action taken
by whom:
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