Fillable On- line Application Form (Broxtowe Borough Council)

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On- line Application Form (Broxtowe Borough Council)

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On- line Application Form
Application for a Case Review
If there have been three complaints about three separate incidents within six months of
anti-social behaviour to any agency and you feel the response was inadequate, under the
Broxtowe Community Trigger Procedure our Complaints Officer will acknowledge receipt of your
complaint and the Head of Public Protection will convene a meeting to review the details of your
complaint and decide if your application is a Qualifying Complaint. Please complete this
application form and we will endeavour to contact you again within 20 working days of receipt of
this form.
The Crime & Disorder Act 1998 and the Data Protection Act 1998 allow agencies to share
relevant personal and sensitive details appropriately with other statutory partners in the
Borough. Information may be stored in a hard copy file and/or electronically and will be
destroyed in compliance with data protection principles. By completing this form you agree to
these conditions.
Complainant/Victim Details
Complainants Name
Address
Email
Agency, organisation or
group (if applicable)
Date of Birth
Phone No.
Describe any relevant
vulnerabilities
Advocate(helper) Details
Organisation
(if applicable)
Email
Phone No.
Declaration
I agree that information about me relevant to my complaint of anti-social behaviour can be shared between
organisations for the purpose of investigating my complaint.
Signature
Date
2
In this section please complete the details of the three complaints you have made about anti-
social behaviour which you want local agencies to review. These incidents must have been
reported in the last six months.
Reported Incidents
INCIDENT ONE
Must have been reported within one month of the incident occurring
Date and Time of
Incident
Name
Organisation
Phone Email/On-line Written In Person
Date you reported this
incident
Brief Details and
Location
Reported to
Incident/Crime or
Reference No.
Method of Reporting
(tick applicable)
Was any action taken, if
so by whom?
INCIDENT TWO
Must have been reported within six months of reporting incident one
Date and Time of
Incident
Name
Organisation
Phone Email/On-line Written In Person
Date you reported this
incident
Brief Details and
Location
Reported to
Incident/Crime or
Reference No.
Method of Reporting
(tick applicable)
Was any action taken, if
so by whom?
3
INCIDENT THREE
Must have been reported within six months of reporting incident one
Date and Time of
Incident
Name
Organisation
Phone Email/On-line Written In Person
Date you reported this
incident
Brief Details and
Location
Reported to
Incident/Crime or
Reference No.
Method of Reporting
(tick applicable)
In this section please explain why you think your case should be reviewed, describe the current
situation and how the anti-social behaviour makes you feel. Please also explain how you would
like to see the matter resolved; you should note however that it may not be possible to meet
your expectations for a resolution, and we will explain why if this is the case.
Reason for Requesting a Case Review
What is the current situation?
Please confirm what action (if any) has been taken.
4
How would you like this matter to be resolved?
How are these incidents affecting you?
Now you have completed the form please submit it or send to:
Complaints Officer
Broxtowe Borough Council
Foster Avenue
Beeston
Nottingham
NG9 1AB
tel:0115 917 3576
typetalk:18001 0115 917 7777
www.broxtowe.gov.uk
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On- line Application Form (Broxtowe Borough Council)

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Completed 8 January 2021

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