Zero Tolerance to Racism

If you are filling in this form, you have likely experienced or witnessed some form of racism. By giving us as much information as you can, you will help us to support you and other BAME staff. If possible, please give contact details. We need to gather information about the incident and work on an intervention that will address the problem. Our aim is to create a fairer and more inclusive place to work, so thank you for telling us. We hope this will benefit not only you as an individual, but remove racism for BAME staff in the future. If you do give us your contact details, a member of the Circle Group will contact you for more information. This is to help us understand what your expectation of a resolution would be.

Reference

I am reporting on behalf of:(Required)

Myself

Someone else

Is this person aware that you are reporting this?(Required)

Yes

Do you wish to provide their contact details?(Required)

Yes

This will allow us to follow up with them.

Do you wish to provide your contact details?(Required)

Yes

This will allow us to follow up with you.

Who is involved?(Required)

A member of staff

A service user

Other

Please select all that apply.

As you selected Other, please specify.(Required)

Ethnicity

Collecting ethnicity data helps us to see which groups of staff are most frequently subject to discrimination, bullying and harassment, and acts of aggression and violence. It also helps us to recognise which staff might not be reporting such incidents. It enables us to work with those staff to understand how we can support them in the future.

I identify as…

I'm reporting on behalf of someone else and they identify as…

Details of the event

Where did the event take place?(Required)

Please be as specific as you can with the location.

What was the date of the event?(Required)

What was the time of the event?(Required)

Who witnessed the event?(Required)

Please give specific names and identifiable information.

Do you require immediate contact or support?(Required)

Yes

Does the recipient require immediate contact or support?(Required)

Yes

You've said you need immediate contact or support, but you've also opted to remain anonymous. How should we support you?(Required)

You've said the recipient needs immediate contact or support, but you've also opted not to provide their contact details. How should we support them?(Required)

Who were the affected people during the event?(Required)

For example, what was the impact on bystanders and the wider team?

Which of the following would best describe the situation?(Required)

Threat

Violence

Racist verbal abuse

Intimidation

Verbal and non-verbal micro-aggressions

Harassment

Discrimination

Please describe your event or situation.(Required)

Be as specific and detailed as you can possibly be.

Is this a pattern of behaviour?(Required)

Yes

Have you already raised concerns with anyone?(Required)

Yes

Who?(Required)

What steps have you taken so far to address your concerns?(Required)

What actions have been taken so far, and by whom?(Required)

Were you satisfied with how it was handled?(Required)

Yes

What would you wish to happen?(Required)

My Contact Details

Do you wish to remain anonymous to involved individuals?(Required)

Yes

My Name(Required)

Forename Surname

My Email Address(Required)

My Job Title(Required)

My Department(Required)

My Health Group or Directorate(Required)

Their Contact Details

Their Name(Required)

Forename Surname

Their Email Address(Required)

Their Job Title(Required)

Their Department(Required)

Their Health Group or Directorate(Required)

Phone

This field is for validation purposes and should be left unchanged.

We take your privacy, and the security and confidentiality of healthcare data, extremely seriously. This website has been built with security and confidentiality in mind.

Your IP address is never logged in our database.
Any person identifiable data you submit via this form is stored on a secure database server in England, which only the relevant authorised healthcare professionals can access.
All email notifications containing person identifiable data are sent securely through NHSmail.
Our processes for collecting data via this website have been approved by the Hull University Teaching Hospitals NHS Trust Information Governance Committee.
We are fully compliant with GDPR and the Data Protection Act 2018.
If you have any questions or concerns about this form, please contact the Digital Communications Team.