ASB1
COMPLAINANT INTERVIEW FORM
SECTION 1 - CASE DETAILS
Complainant Details
Name(s):
Address:
`
Tel No:
D.O.B
Tenure Type
Gender
Ethnicity
Subject Details:
Name:
Address or
location:
SECTION 2 - CURRENT ISSUES
What are the key issues (summary of complaint/incidents)
Page 1 of 6
(v2)
Chevin
Green Vale Homes
Housing Pendle
Pennine Housing 2000
Twin Valley Homes
What are the key issues (continued)
SECTION 3 - RISK ASSESSMENT
Response
1. Other than this occasion – how often do you
have problems?
5
3
2
1
0
-
Daily
Most Days
Most Weeks
Most Months
Only Occasionally
2. Do you think the current incident is linked to
previous incidents?
2
0
- Yes
- No
Is so, why?
3. Do you think that the incidents are happening
more often and/or getting worse?
2
0
- Yes
- No
Is so, why?
4. Do you know the offender/s
HISTORY
2
1
0
- They know each other well
- They are ‘known’ to each other
- They do not know each other
Provide details:
4.1
Has the Complainant challenged the subject or
householder regarding their behaviour
(Yes / No)
4.2
Are they any underlying reasons why the
nuisance is occurring and/or is there a history
between the parties (Yes / No) – If Yes what is it?
5. Does the Subject/Perpetrator (or their
associates) have a history or reputation for
intimidation or harassment?
6
4
2
0
- Perpetrator or their associates are currently
harassing the complainant
- Perpetrator or their associates have harassed
the complainant in the past
- Perpetrator or their associates have not
harassed the complainant, but have a history
or reputation for harassment or violent
behaviour
- Perpetrator or their associates have no history
or reputation for harassment or intimidation
6. Have you informed any other agencies about
what has happened?
0
1
- Yes
- No
If Yes – are you happy for us to discuss this problem
with them (Yes / No) - Provide details of agency etc
Page 2 of 6
(v2)
Response
7. Which of the following do you think this incident
deliberately targeted?
4
3
1
0
-
You
Your family
Your Community
None
Specify:
VULNERABILITY
8. Do you feel that this incident is associated with
your faith, nationality, ethnicity, sexuality,
gender, disability, alternative subculture?
3
0
- Yes
- No
Provide details9. In addition to what has happened, do you feel
that there is anything that is increasing you or
your household’s personal risk (e.g. because of
personal circumstances)
3
0
- Yes
- No
Provide details 10. How effected do you feel by what has
happened?
0
1
2
3
5
-
Not at all
Affected a little
Moderately affected
Affected a lot
Extremely effected
Provide details:
11. Has yours or anyone’s health been affected as
a result of this or previous incidents?
3
3
0
- Physical health
- Mental health
- None
Provide details:
11.1 Have you or anyone in your household have a
disability or long term illness (Yes/No) - (Long
SUPPORT
standing means something that has lasted over 12 month) -
If Yes – highlight name of person and their
associated disability or long term illness
12. Do you have a social worker, health visitor,
mental health worker, GP or any other type of
professional support?
0
1
- No
- Yes
Provide details- (If appropriate seek complainants GP
name and surgery address)
12.1 Do you wish to be referred to any supporting
agencies?
Page 3 of 6
(v2)
Response
13. Do you have any friends and family to support
you?
3
3
1
0
- Complainant lives alone and is isolated
- The complainant is isolated from people who
can offer support
- The complainant has a few people to draw on
for support
- The complainant has a close network of people
to draw on for support
SUPPORT
Expand 14. Apart from any effect on you, do you think
anyone else has been affected by what has
happened?
1
3
0
- Your family
- Local Community
- Other
Provide details:
14.1 Has anyone else witnesses the incidents or
can anyone provide support evidence
(Yes / NO) If Yes provide name/address/contact details
SECTION 3 - RAM SCORE
ASB Risk Assessment Score from Section 3 Q1 - Q14
Score:
To be referred to ASBRAC/Vulnerability Panel
Guidance:
0 – 15
Referral not required
YES
16 – 23
NO
Consider referral
If No, why not?
24 or More – Make a referral
The Guidance is to assist officers in making a decision on referral – however, the interviewing officer should take into account the circumstances of the case and decide appropriately.
SECTION 4 – ADDITIONAL SUPPORT
Does the complainant have any difficulty in reading and understanding
English?
YES
NO
If YES, do they need any assistance in completing Incident Report Sheets, understanding letters, requires a translator –
Highlight below:
SECTION 5 – ADDITIONAL INFORMATION
Page 4 of 6
(v2)
Chevin
Green Vale Homes
Housing Pendle
Pennine Housing 2000
Twin Valley Homes
ANTI-SOCIAL BEHAVIOUR & NUISANCE (S6)
ACTION PLAN
This action plan has been agreed between:
COMPLAINANT
Interviewing Officer
Name(s):
Name:
Address:
Job Title:
Tel No:
Tel No:
This plan sets out the actions both parties will take to try to resolve the complaint
ACTIONS AGREED BY COMPLAINANT
CONTACT & METHOD

Daily
Fortnightly
Monthly
Letter
E-mail
Home visit
Weekly
Fortnightly
Monthly
Not to contact
Other
Preferred method of contact:
Daily

Weekly
THG to contact the complainant:
Telephone

ACTIONS AGREED BY OFFICER:
When nuisance occurs
Complainant to contact THG:
Signature:
I agree and consent to this action plan and I will complete any actions which have been asked of me.
Complainants Signature(s):
Signature of Interviewing Officer:
Date action plan agreed:
Case Ref No:
Page 5 of 6
(v2)
SECTION 7 - INFORMATION SHARING CONSENT
I agree to the disclosure, receipt, sharing and exchanging of information between all relevant agencies
in respect of my:


Reported incidents or associated information in respect of nuisance, anti-social behaviour
or harassment complaint.
Personal details and health issues which may have a bearing on the successful resolution
of the case.
I understand that the agencies in which information may be shared include: (this list is not exhaustive)
Police, Social Services, Community Mental Health/GP, Local Authority, Community Safety Teams, other
statutory and voluntary agencies.
Consent Given
Consent Refused
If consent refused, why?
SECTION 8 - SIGNATURE
I/we confirm that the details stated in this form are true:
Signature of
Complainant (s):
Date:
Signature of
Interviewing Officer:
Date:
Method of interview:
OFFICE
HOME VISIT
Any other people present at the interview:
SECTION 9 – ADDITIONAL NOTES FOR OFFICER
Page 6 of 6
(v2)
TELEPHONE