Below are all the questions included in the Report with Contact Details Form. This shows all of the questions you may be asked, in the information below you will see the guidance of when this question is asked. At the top of each page there is a link to google translate.
The line reads: " If you need help to translate these questions, you can copy and paste the options into Google Translate."
Page 1
Thank you for choosing to report something that has happened. Things might feel difficult or tough now, but by choosing to provide your contact details we are able to help provide you with better support and stop something similar from happening to anyone else.
Reminder: Please do not report patient safety concerns via Report and Support. This platform is for staff concerns only. All incidents involving a patient, near misses or concerns must still be reported through datix. This includes patient behaviour towards staff.
This report will remain confidential and the information you share will only be passed on to relevant staff on a strictly need to know basis. We will not disclose any personal or identifiable information to others unless we believe there is a genuine threat to a person’s health and safety.
Your report will be handled by staff in the People Hub. If you wish for your report to be supported by Freedom to Speak Up, please select 'yes' when asked. You can read our Frequently Asked Questions or process flowchart if you require more information about how we process reports.
Your data is important to us. We won’t collect or store any information that goes against our privacy notice. A member of the People Hub will be in touch with you within 3 working days.
Page 2
2.1: Incident happened to
The reporter must select exactly 1 option.
I am reporting something which has: (required)
Options:
Happened to me
Happened to someone else
2.2: Reporter role
The reporter must select exactly 1 option.
Prompts: The person I am reporting on behalf of is (required) (when "Incident happened to" has been answered with Happened to someone else) I am a: (required) (default).
Options:
Member of staff
Member of bank staff
Contractor
Locum or temporary staff
Student or trainee
Other – When ticked, a free-text box appears and must be completed.If other, please specify
2.3: Team/department The reporter must select exactly 1 option.
I work in: (required)
Options:
Corporate Division
Chief Executive
Commercial and Strategic Development
Education
Finance
Human Resources [Directorate]
Information Technology
Nursing & Patient Care [Directorate]
Occupational Health
Patient Care Delivery
Staffing Solutions
Undergraduate Admin
Estates and Facilites
Catering
Cleaning
Facilities – Central
Logistics
Maintenance
Safety & Security
Sterilisation
Family and Specialist Services (FaSS)
Division Breast Unit [Directorate]
Cancer Services
FaSS Management
Fatigue Services
Gynaecology
Maternity Services
Oncology
Paed & NICU
Pharmacy [Directorate]
Sexual Health
Medical Division
Acute Medicine
Cardiology
Dermatology
Emergency Medicine
Endocrinology
Gastroenterology
Medical Physics
Medicine Management
Neurology
Older People’s Unit
Radiology
Respiratory
Rheumatology
Stroke
Therapy Services
Research and Development
Surgical Division
Anaesthesia
ENT
General Surgery
ITU Directorate
Ophthalmology
Oral, Mac-Fac & Orth
Pain Service
Pathology
Records & Bookings
Surgery Management
Theatres
Trauma & Orthopaedics
Urology
Other options
Other – When ticked, a free-text box appears and must be completed. If other, please specify
Prefer not to say
I don't know
Page 3
This page is only shown if "Incident happened to" has been answered with Happened to someone else.
3.1: Reporting on behalf of role
The reporter must select exactly 1 option.
The person I am reporting on behalf of is a
Options:
Member of staff
Member of bank staff
Contractor
Locum or temporary staff
Student or trainee
Other – When ticked, a free-text box appears and must be completed.If other, please specify.
Page 4
4.1: Reported party role
The reporter must select exactly 1 option.
I think the person I am reporting is a: (required)
Options:
Member of staff
Member of bank staff
Contractor
Locum or temporary staff
Student or trainee
Other – When ticked, a free-text box appears and must be completed.If other, please specify.
Page 5
5.1: Reported party team
The reporter must select exactly 1 option.
The person(s) I am reporting works in: (required)
Options:
Corporate Division
Chief Executive
Commercial and Strategic Development
Education
Finance
Human Resources [Directorate]
Information Technology
Nursing & Patient Care [Directorate]
Occupational Health
Patient Care Delivery
Staffing Solutions
Undergraduate Admin
Estates and Facilites
Catering
Cleaning
Facilities – Central
Logistics
Maintenance
Safety & Security
Sterilisation
Family and Specialist Services (FaSS)
Division Breast Unit [Directorate]
Cancer Services
FaSS Management
Fatigue Services
Gynaecology
Maternity Services
Oncology
Paed & NICU
Pharmacy [Directorate]
Sexual Health
Medical Division
Acute Medicine
Cardiology
Dermatology
Emergency Medicine
Endocrinology
Gastroenterology
Medical Physics
Medicine Management
Neurology
Older People’s Unit
Radiology
Respiratory
Rheumatology
Stroke
Therapy Services
Research and Development
Surgical Division
Anaesthesia
ENT
General Surgery
ITU Directorate
Ophthalmology
Oral, Mac-Fac & Orth
Pain Service
Pathology
Records & Bookings
Surgery Management
Theatres
Trauma & Orthopaedics
Urology
Other options
Other – When ticked, a free-text box appears and must be completed. If other, please specify
Prefer not to say
I don't know
Page 6
6.1: Incident Type
The reporter must select at least 1 option.
I would describe what happened as:
Select all that apply (required)
Options:
Cultural Concern
Pop-out definition (only when selected): In the context of the workplace, culture is the everyday behaviours, values and practices that are widely shared, respected and rewarded, regardless of their outcome. Broadly, culture is not behaviours that target individuals (this type of behaviour is more likely to be bullying, discrimination, or harassment), but instead is observed and experienced over time. Certain aspects of culture may have a disproportionately positive or negative impact on an individual or group of individuals, and there may not be an obvious reason for this.
Cultural concerns can range from regular social activities that exclude certain individuals, ‘banter’ or what is viewed as humour being derogatory, or the way that colleagues interact with one another feeling disrespectful.
Bullying
Pop-out definition (only when selected) Characterised as offensive, intimidating, malicious or insulting behaviour or an abuse of authority through means intended to undermine, humiliate, denigrate or injure the recipient.
Bullying and/or harassment may be by an individual against an individual, perhaps by someone in a position of authority such as a manager or supervisor, or involve groups of people. A manager may be bullied by a direct report. Bullying and/or harassment may be obvious or it may be insidious.
Whatever form bullying and/or harassment takes, it is unwarranted and unwelcome to the individual.
Discrimination
Pop-out definition (only when selected): Discrimination is where you have been treated differently just because of a protected characteristic (for example, age, disability, gender reassignment, race, religion or belief, sex, or sexual orientation).
It may result in, for example, not being selected to work on a particular project, not being promoted, or assumptions being made that you cannot do something because of your personal characteristics or situation.
Harassment
Pop-out definition (only when selected): Harassment is unwanted conduct related to a relevant protected characteristic, which has the purpose or effect of violating an individual’s dignity or creating an intimidating, hostile, degrading, humiliating or offensive environment for that individual’.
The relevant protected characteristics are age, disability, gender reassignment, race, religion or belief, sex and sexual orientation.
Harassment may be persistent or an isolated incident. The key element is that the actions or comments are viewed as demeaning and unacceptable to the recipient.
Sexual Harassment or Inappropriate Contact
Pop-out definition (only when selected): Sexual harassment refers to unwanted conduct or advances of a sexual nature, whether in person or online. It can include unwanted physical touching, leering, making sexual comments or jokes, posting sexual pictures online/ group chats or suggestions of benefits in return for sexual favours.
Inappropriate contact refers to unwanted physical or online contact that is often, though not always, sexual in nature.
Physical assault
Pop-out definition (only when selected): Physical assault is when an individual or a group attacks, or attempts to attack a person physically, or threatens to hurt that person. It can be with or without the use of a weapon, and can include scratching, pushing, kicking, punching, throwing things, or physically restraining another person.
Radicalisation, hate and extremism
Pop-out definition (only when selected): Radicalisation and extremism occur when someone starts to believe or engage with extreme views or hateful confrontational or violent language or behaviours in support of a political or social cause. It can be motivated by a range of factors, including ideologies, religious beliefs, political beliefs and prejudices against particular groups of people.
Other – When ticked, a free-text box appears and can optionally be completed.(optional)
Pop-out definition (only when selected): This covers things that don't feel right, or behaviour that you've noticed but doesn't quite fall into any of other categories
Page 7
7.1: Location
The reporter must select at least 1 option.
Where did the incident occur? (required)
Options:
In the community
Online (email/social media)
Online Teams meeting
On the RUH (Combe Park) Site
Riverside
Other – When ticked, a free-text box appears and must be completed. If other, please specify
Community Birthing Centre:
Chippenham
Frome
Paulton
Trowbridge
7.2: Incident Details - named
The reporter must answer this question to continue.
This question is a multi-line free-text box.
Please tell us what has happened (required)
We know that writing about a negative or distressing experience can be a really difficult thing to do, and we encourage you to only write what feels comfortable for you here at the moment.
If you can let us know the main points, it will help us to understand the situation and be in the best place to support you. Helpful details to include are: date, location, names of the people involved. You will have every opportunity to add further information when you have a conversation with a member of the People Hub team.
7.3: How often
The reporter must select exactly 1 option.
How often has this occurred? (required)
Options:
One off
Multiple occasions
Don’t know
7.4: Image
The reporter can optionally answer this question. This question asks for an image
I would like to upload an image related to what happened (optional)
This could be a screenshot or image of what happened
Page 8
8.1: Reported previously
The reporter must select at least 1 option.
Have you already reported the incident(s), or informed a member of staff? (required)
You can select multiple options
Options:
Yes: To my line manager / a senior leader
Yes: To HR
Yes: To a Union
Yes: To an external organisation
Yes: Other – When ticked, a free-text box appears and can optionally be completed.
No
Page 9
Freedom to Speak Up is an independent service to support staff when all other avenues of speaking up have been used.
All reports are handled by the People Hub Team. If you would prefer for your report to be supported by the Freedom to Speak Up Guardian select ‘Yes’, your report will be submitted to Freedom to Speak Up directly.
This means your report will not be handled by the People Hub Team and the first person to review your report is the Freedom to Speak Up Guardian. As it is anonymous they will not contact you, but will use your report to analyse themes and share information with the organisation.
9.1: FTSU Guardian
The reporter must select exactly 1 option.
Do you want your report to be supported by the Freedom to Speak Up Guardian? (required)
Options:
Yes
No
Page 10
10.1: Suspected factors
This question is optional, the reporter can select multiple options or none at all.
Do you feel that any of the following were motivating factors in what you are reporting? Select all that apply (optional)
Options:
Age
Pop-out definition (only when selected): A person belonging to a particular age (for example 32 year olds) or range of ages (for example 18 to 30 year olds)
Disability
Pop-out definition (only when selected): A person has a disability if she or he has a physical or mental impairment which has a substantial and long-term adverse effect on that person's ability to carry out normal day-to-day activities
Race/Ethnicity/Nationality
Pop-out definition (only when selected): A race is a group of people defined by their colour, nationality (including citizenship) ethnicity or national origins. A racial group can be made up of more than one distinct racial group, such as Black British.
Sex
Pop-out definition (only when selected): Sex discrimination is when you are treated differently because of your sex as a man or woman.
Having children
Having caring responsibilities
Pop-out definition (only when selected): Carers look after family members and friends requiring assistance due to illness, disability or other care and support needs. They may provide physical, medical or practical assistance and emotional support
Religion or belief
Pop-out definition (only when selected): Religion refers to any religion, including a lack of religion. Belief refers to any religious or philosophical belief and includes a lack of belief. Generally, a belief should affect your life choices or the way you live for it to be included in the definition.
Sexual orientation
Pop-out definition (only when selected): Whether a person's sexual attraction is towards their own sex, the opposite sex or to both sexes.
Socio-economic background
Pop-out definition (only when selected): Socio-economic background relates to a combination of an individual’s income, occupation and social background.
Trans-gender or non-binary identity
Pop-out definition (only when selected): Transgender, or trans, is an umbrella term for people whose gender identity is different from the sex assigned to them at birth. Non-binary is an identity embraced by some people who do not identify exclusively as a man or a woman.
Other – When ticked, a free-text box appears and can optionally be completed.(optional) None of the above
Page 11
Contacting you
11.1: Name The reporter must answer this question to continue. This question is a free-text box.
11.2: Contact preference
The reporter must select at least 1 option.
How would you prefer to be contacted? (required)
Please choose the best way to contact you. If you are happy to be contacted by either phone or email please select both options and provide your details.
Options:
Email – When ticked, a free-text box appears and must be completed.
Phone – When ticked, a free-text box appears and must be completed.
Page 12
This page is only shown if "Incident happened to" has been answered with Happened to me .
This question is optional, the reporter can select multiple options or none at all.
These questions help us to understand what is happening across our community. We want to make the RUH a safe and inclusive place to work. Understanding more about you is essential to help us to recognise patterns of behaviour towards groups of people and prevent similar incidents from happening to others.
Find out more about how your information helps.
12.1: Age group
How old are you?
Options: Your age is
16 – 20
21 – 30
31-40
41-50
51-65
66+
Prefer not to say
12.2: Gender
How do you define your gender?
Options: Your gender is
Man
Non-binary
Transgender Man
Transgender Woman
Woman
Other
Prefer not to say
12.3: Disability
Do you have a disability or long term health condition?
A disability can be an impairment, health condition or neurodiversity that has a substantial and long term impact on your ability to carry out normal day-to-day activities
Options: Do you have a disability?
Yes
No
Prefer not to say
12.4: Ethnic group
How would you describe your ethnic group?
Options:
Asian or Asian British (Includes any Asian background, for example, Bangladeshi, Chinese, Indian, Pakistani)
Asian or Asian British - Bangladeshi
Asian or Asian British - Chinese
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Another Asian background – When ticked, a free-text box appears and can optionally be completed.(optional)
Black, African, Black British or Caribbean (Includes any Black background)
Black or Black British - African
Black or Black British - Caribbean
Another Black background – When ticked, a free-text box appears and can optionally be completed.(optional)
Mixed or multiple ethnic groups (Includes any Mixed background)
Mixed or multiple background - Asian and White
Mixed or multiple background - Black African and White
Mixed or multiple background - Black Caribbean and White
Another Mixed or Multiple background – When ticked, a free-text box appears and can optionally be completed.(optional)
White (Includes any White background)
White - British, Northern Irish, Scottish, Welsh
White - Irish
White - Irish Traveller or Gypsy
Another White background – When ticked, a free-text box appears and can optionally be completed.(optional)
Another ethnic group
Arab
Another ethnic group – When ticked, a free-text box appears and can optionally be completed.(optional)
Other options
Other – When ticked, a free-text box appears and can optionally be completed.(optional)
Prefer not to say
12.5: Faith/religion
Do you have a religion or belief?
Options: Your religion or belief?
None
Buddhist
Christian (including Catholic, Protestant or any other denomination)
Hindu
Jewish
Muslim
Sikh
Other – When ticked, a free-text box appears and can optionally be completed.(optional)
Prefer not to say
12.6: Sexual orientation
How do you define your sexual orientation?
Options: Your sexual orientation
Asexual
Bisexual
Gay man
Heterosexual
Lesbian/Gay woman
Pansexual
Other – When ticked, a free-text box appears and can optionally be completed.(optional)
Prefer not to say
Page 13
By submitting this form you agree for us to contact you using the information provided in line with our privacy policy.
If you would prefer not to provide this information you can choose to submit the information anonymously instead. Information already entered will be copied over to the new report. When you report anonymously we will not be able to come back to you or help you directly with your concern. Always think carefully about what is best for you and what support you need.
Report anonymously or continue by selecting the 'Send report' button below.
Thank You Page
Reporting can feel tough and we appreciate the time and effort you've taken to submit a report.
If you need immediate support here are some articles that might help.
Your report has been submitted. The relevant team will be in contact with you within 3 working days. We will only contact you based on your preferred method of contact.
We won't take any further action without your consent.
Your case reference number:
The line reads: " If you need help to translate these questions, you can copy and paste the options into Google Translate."
Page 1
Thank you for choosing to report something that has happened. Things might feel difficult or tough now, but by choosing to provide your contact details we are able to help provide you with better support and stop something similar from happening to anyone else.
Reminder: Please do not report patient safety concerns via Report and Support. This platform is for staff concerns only. All incidents involving a patient, near misses or concerns must still be reported through datix. This includes patient behaviour towards staff.
This report will remain confidential and the information you share will only be passed on to relevant staff on a strictly need to know basis. We will not disclose any personal or identifiable information to others unless we believe there is a genuine threat to a person’s health and safety.
Your report will be handled by staff in the People Hub. If you wish for your report to be supported by Freedom to Speak Up, please select 'yes' when asked. You can read our Frequently Asked Questions or process flowchart if you require more information about how we process reports.
Your data is important to us. We won’t collect or store any information that goes against our privacy notice. A member of the People Hub will be in touch with you within 3 working days.
Page 2
2.1: Incident happened to
The reporter must select exactly 1 option.
I am reporting something which has: (required)
Options:
Happened to me
Happened to someone else
2.2: Reporter role
The reporter must select exactly 1 option.
Prompts: The person I am reporting on behalf of is (required) (when "Incident happened to" has been answered with Happened to someone else) I am a: (required) (default).
Options:
Member of staff
Member of bank staff
Contractor
Locum or temporary staff
Student or trainee
Other – When ticked, a free-text box appears and must be completed.If other, please specify
2.3: Team/department The reporter must select exactly 1 option.
I work in: (required)
Options:
Corporate Division
Chief Executive
Commercial and Strategic Development
Education
Finance
Human Resources [Directorate]
Information Technology
Nursing & Patient Care [Directorate]
Occupational Health
Patient Care Delivery
Staffing Solutions
Undergraduate Admin
Estates and Facilites
Catering
Cleaning
Facilities – Central
Logistics
Maintenance
Safety & Security
Sterilisation
Family and Specialist Services (FaSS)
Division Breast Unit [Directorate]
Cancer Services
FaSS Management
Fatigue Services
Gynaecology
Maternity Services
Oncology
Paed & NICU
Pharmacy [Directorate]
Sexual Health
Medical Division
Acute Medicine
Cardiology
Dermatology
Emergency Medicine
Endocrinology
Gastroenterology
Medical Physics
Medicine Management
Neurology
Older People’s Unit
Radiology
Respiratory
Rheumatology
Stroke
Therapy Services
Research and Development
Surgical Division
Anaesthesia
ENT
General Surgery
ITU Directorate
Ophthalmology
Oral, Mac-Fac & Orth
Pain Service
Pathology
Records & Bookings
Surgery Management
Theatres
Trauma & Orthopaedics
Urology
Other options
Other – When ticked, a free-text box appears and must be completed. If other, please specify
Prefer not to say
I don't know
Page 3
This page is only shown if "Incident happened to" has been answered with Happened to someone else.
3.1: Reporting on behalf of role
The reporter must select exactly 1 option.
The person I am reporting on behalf of is a
Options:
Member of staff
Member of bank staff
Contractor
Locum or temporary staff
Student or trainee
Other – When ticked, a free-text box appears and must be completed.If other, please specify.
Page 4
4.1: Reported party role
The reporter must select exactly 1 option.
I think the person I am reporting is a: (required)
Options:
Member of staff
Member of bank staff
Contractor
Locum or temporary staff
Student or trainee
Other – When ticked, a free-text box appears and must be completed.If other, please specify.
Page 5
5.1: Reported party team
The reporter must select exactly 1 option.
The person(s) I am reporting works in: (required)
Options:
Corporate Division
Chief Executive
Commercial and Strategic Development
Education
Finance
Human Resources [Directorate]
Information Technology
Nursing & Patient Care [Directorate]
Occupational Health
Patient Care Delivery
Staffing Solutions
Undergraduate Admin
Estates and Facilites
Catering
Cleaning
Facilities – Central
Logistics
Maintenance
Safety & Security
Sterilisation
Family and Specialist Services (FaSS)
Division Breast Unit [Directorate]
Cancer Services
FaSS Management
Fatigue Services
Gynaecology
Maternity Services
Oncology
Paed & NICU
Pharmacy [Directorate]
Sexual Health
Medical Division
Acute Medicine
Cardiology
Dermatology
Emergency Medicine
Endocrinology
Gastroenterology
Medical Physics
Medicine Management
Neurology
Older People’s Unit
Radiology
Respiratory
Rheumatology
Stroke
Therapy Services
Research and Development
Surgical Division
Anaesthesia
ENT
General Surgery
ITU Directorate
Ophthalmology
Oral, Mac-Fac & Orth
Pain Service
Pathology
Records & Bookings
Surgery Management
Theatres
Trauma & Orthopaedics
Urology
Other options
Other – When ticked, a free-text box appears and must be completed. If other, please specify
Prefer not to say
I don't know
Page 6
6.1: Incident Type
The reporter must select at least 1 option.
I would describe what happened as:
Select all that apply (required)
Options:
Cultural Concern
Pop-out definition (only when selected): In the context of the workplace, culture is the everyday behaviours, values and practices that are widely shared, respected and rewarded, regardless of their outcome. Broadly, culture is not behaviours that target individuals (this type of behaviour is more likely to be bullying, discrimination, or harassment), but instead is observed and experienced over time. Certain aspects of culture may have a disproportionately positive or negative impact on an individual or group of individuals, and there may not be an obvious reason for this.
Cultural concerns can range from regular social activities that exclude certain individuals, ‘banter’ or what is viewed as humour being derogatory, or the way that colleagues interact with one another feeling disrespectful.
Bullying
Pop-out definition (only when selected) Characterised as offensive, intimidating, malicious or insulting behaviour or an abuse of authority through means intended to undermine, humiliate, denigrate or injure the recipient.
Bullying and/or harassment may be by an individual against an individual, perhaps by someone in a position of authority such as a manager or supervisor, or involve groups of people. A manager may be bullied by a direct report. Bullying and/or harassment may be obvious or it may be insidious.
Whatever form bullying and/or harassment takes, it is unwarranted and unwelcome to the individual.
Discrimination
Pop-out definition (only when selected): Discrimination is where you have been treated differently just because of a protected characteristic (for example, age, disability, gender reassignment, race, religion or belief, sex, or sexual orientation).
It may result in, for example, not being selected to work on a particular project, not being promoted, or assumptions being made that you cannot do something because of your personal characteristics or situation.
Harassment
Pop-out definition (only when selected): Harassment is unwanted conduct related to a relevant protected characteristic, which has the purpose or effect of violating an individual’s dignity or creating an intimidating, hostile, degrading, humiliating or offensive environment for that individual’.
The relevant protected characteristics are age, disability, gender reassignment, race, religion or belief, sex and sexual orientation.
Harassment may be persistent or an isolated incident. The key element is that the actions or comments are viewed as demeaning and unacceptable to the recipient.
Sexual Harassment or Inappropriate Contact
Pop-out definition (only when selected): Sexual harassment refers to unwanted conduct or advances of a sexual nature, whether in person or online. It can include unwanted physical touching, leering, making sexual comments or jokes, posting sexual pictures online/ group chats or suggestions of benefits in return for sexual favours.
Inappropriate contact refers to unwanted physical or online contact that is often, though not always, sexual in nature.
Physical assault
Pop-out definition (only when selected): Physical assault is when an individual or a group attacks, or attempts to attack a person physically, or threatens to hurt that person. It can be with or without the use of a weapon, and can include scratching, pushing, kicking, punching, throwing things, or physically restraining another person.
Radicalisation, hate and extremism
Pop-out definition (only when selected): Radicalisation and extremism occur when someone starts to believe or engage with extreme views or hateful confrontational or violent language or behaviours in support of a political or social cause. It can be motivated by a range of factors, including ideologies, religious beliefs, political beliefs and prejudices against particular groups of people.
Other – When ticked, a free-text box appears and can optionally be completed.(optional)
Pop-out definition (only when selected): This covers things that don't feel right, or behaviour that you've noticed but doesn't quite fall into any of other categories
Page 7
7.1: Location
The reporter must select at least 1 option.
Where did the incident occur? (required)
Options:
In the community
Online (email/social media)
Online Teams meeting
On the RUH (Combe Park) Site
Riverside
Other – When ticked, a free-text box appears and must be completed. If other, please specify
Community Birthing Centre:
Chippenham
Frome
Paulton
Trowbridge
7.2: Incident Details - named
The reporter must answer this question to continue.
This question is a multi-line free-text box.
Please tell us what has happened (required)
We know that writing about a negative or distressing experience can be a really difficult thing to do, and we encourage you to only write what feels comfortable for you here at the moment.
If you can let us know the main points, it will help us to understand the situation and be in the best place to support you. Helpful details to include are: date, location, names of the people involved. You will have every opportunity to add further information when you have a conversation with a member of the People Hub team.
7.3: How often
The reporter must select exactly 1 option.
How often has this occurred? (required)
Options:
One off
Multiple occasions
Don’t know
7.4: Image
The reporter can optionally answer this question. This question asks for an image
I would like to upload an image related to what happened (optional)
This could be a screenshot or image of what happened
Page 8
8.1: Reported previously
The reporter must select at least 1 option.
Have you already reported the incident(s), or informed a member of staff? (required)
You can select multiple options
Options:
Yes: To my line manager / a senior leader
Yes: To HR
Yes: To a Union
Yes: To an external organisation
Yes: Other – When ticked, a free-text box appears and can optionally be completed.
No
Page 9
Freedom to Speak Up is an independent service to support staff when all other avenues of speaking up have been used.
All reports are handled by the People Hub Team. If you would prefer for your report to be supported by the Freedom to Speak Up Guardian select ‘Yes’, your report will be submitted to Freedom to Speak Up directly.
This means your report will not be handled by the People Hub Team and the first person to review your report is the Freedom to Speak Up Guardian. As it is anonymous they will not contact you, but will use your report to analyse themes and share information with the organisation.
9.1: FTSU Guardian
The reporter must select exactly 1 option.
Do you want your report to be supported by the Freedom to Speak Up Guardian? (required)
Options:
Yes
No
Page 10
10.1: Suspected factors
This question is optional, the reporter can select multiple options or none at all.
Do you feel that any of the following were motivating factors in what you are reporting? Select all that apply (optional)
Options:
Age
Pop-out definition (only when selected): A person belonging to a particular age (for example 32 year olds) or range of ages (for example 18 to 30 year olds)
Disability
Pop-out definition (only when selected): A person has a disability if she or he has a physical or mental impairment which has a substantial and long-term adverse effect on that person's ability to carry out normal day-to-day activities
Race/Ethnicity/Nationality
Pop-out definition (only when selected): A race is a group of people defined by their colour, nationality (including citizenship) ethnicity or national origins. A racial group can be made up of more than one distinct racial group, such as Black British.
Sex
Pop-out definition (only when selected): Sex discrimination is when you are treated differently because of your sex as a man or woman.
Having children
Having caring responsibilities
Pop-out definition (only when selected): Carers look after family members and friends requiring assistance due to illness, disability or other care and support needs. They may provide physical, medical or practical assistance and emotional support
Religion or belief
Pop-out definition (only when selected): Religion refers to any religion, including a lack of religion. Belief refers to any religious or philosophical belief and includes a lack of belief. Generally, a belief should affect your life choices or the way you live for it to be included in the definition.
Sexual orientation
Pop-out definition (only when selected): Whether a person's sexual attraction is towards their own sex, the opposite sex or to both sexes.
Socio-economic background
Pop-out definition (only when selected): Socio-economic background relates to a combination of an individual’s income, occupation and social background.
Trans-gender or non-binary identity
Pop-out definition (only when selected): Transgender, or trans, is an umbrella term for people whose gender identity is different from the sex assigned to them at birth. Non-binary is an identity embraced by some people who do not identify exclusively as a man or a woman.
Other – When ticked, a free-text box appears and can optionally be completed.(optional) None of the above
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Contacting you
11.1: Name The reporter must answer this question to continue. This question is a free-text box.
11.2: Contact preference
The reporter must select at least 1 option.
How would you prefer to be contacted? (required)
Please choose the best way to contact you. If you are happy to be contacted by either phone or email please select both options and provide your details.
Options:
Email – When ticked, a free-text box appears and must be completed.
Phone – When ticked, a free-text box appears and must be completed.
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This page is only shown if "Incident happened to" has been answered with Happened to me .
This question is optional, the reporter can select multiple options or none at all.
These questions help us to understand what is happening across our community. We want to make the RUH a safe and inclusive place to work. Understanding more about you is essential to help us to recognise patterns of behaviour towards groups of people and prevent similar incidents from happening to others.
Find out more about how your information helps.
12.1: Age group
How old are you?
Options: Your age is
16 – 20
21 – 30
31-40
41-50
51-65
66+
Prefer not to say
12.2: Gender
How do you define your gender?
Options: Your gender is
Man
Non-binary
Transgender Man
Transgender Woman
Woman
Other
Prefer not to say
12.3: Disability
Do you have a disability or long term health condition?
A disability can be an impairment, health condition or neurodiversity that has a substantial and long term impact on your ability to carry out normal day-to-day activities
Options: Do you have a disability?
Yes
No
Prefer not to say
12.4: Ethnic group
How would you describe your ethnic group?
Options:
Asian or Asian British (Includes any Asian background, for example, Bangladeshi, Chinese, Indian, Pakistani)
Asian or Asian British - Bangladeshi
Asian or Asian British - Chinese
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Another Asian background – When ticked, a free-text box appears and can optionally be completed.(optional)
Black, African, Black British or Caribbean (Includes any Black background)
Black or Black British - African
Black or Black British - Caribbean
Another Black background – When ticked, a free-text box appears and can optionally be completed.(optional)
Mixed or multiple ethnic groups (Includes any Mixed background)
Mixed or multiple background - Asian and White
Mixed or multiple background - Black African and White
Mixed or multiple background - Black Caribbean and White
Another Mixed or Multiple background – When ticked, a free-text box appears and can optionally be completed.(optional)
White (Includes any White background)
White - British, Northern Irish, Scottish, Welsh
White - Irish
White - Irish Traveller or Gypsy
Another White background – When ticked, a free-text box appears and can optionally be completed.(optional)
Another ethnic group
Arab
Another ethnic group – When ticked, a free-text box appears and can optionally be completed.(optional)
Other options
Other – When ticked, a free-text box appears and can optionally be completed.(optional)
Prefer not to say
12.5: Faith/religion
Do you have a religion or belief?
Options: Your religion or belief?
None
Buddhist
Christian (including Catholic, Protestant or any other denomination)
Hindu
Jewish
Muslim
Sikh
Other – When ticked, a free-text box appears and can optionally be completed.(optional)
Prefer not to say
12.6: Sexual orientation
How do you define your sexual orientation?
Options: Your sexual orientation
Asexual
Bisexual
Gay man
Heterosexual
Lesbian/Gay woman
Pansexual
Other – When ticked, a free-text box appears and can optionally be completed.(optional)
Prefer not to say
Page 13
By submitting this form you agree for us to contact you using the information provided in line with our privacy policy.
If you would prefer not to provide this information you can choose to submit the information anonymously instead. Information already entered will be copied over to the new report. When you report anonymously we will not be able to come back to you or help you directly with your concern. Always think carefully about what is best for you and what support you need.
Report anonymously or continue by selecting the 'Send report' button below.
Thank You Page
Reporting can feel tough and we appreciate the time and effort you've taken to submit a report.
If you need immediate support here are some articles that might help.
Your report has been submitted. The relevant team will be in contact with you within 3 working days. We will only contact you based on your preferred method of contact.
We won't take any further action without your consent.
Your case reference number: