🏡 Community Feedback Form 🚔

Dear Resident/Business Owner,

As part of our ongoing efforts to improve the local area, we are seeking feedback regarding any concerns, issues, or anti-social behaviour affecting your community.

💬 Your responses will help us identify local priorities and take appropriate action where possible.

👤 Your Details

Name: ___________________________________________

🏠 Address / Business Name: ___________________________

📞 Contact Number (optional): __________________________

📧 Email Address (optional): ___________________________

🚨 Community Concerns

1. Are there any issues in your area that you would like us to be aware of?

☐ ✅ Yes
☐ ❌ No

2. How often does this issue occur?

☐ 📅 Daily
☐ 📆 Weekly
☐ 🗓️ Monthly
☐ 🔹 Occasionally
☐ ✏️ Other: __________________________

3. 📍 Where is the issue occurring?

4. 📝 Please provide any additional information that may assist us (e.g. times, dates, descriptions, names or vehicle details where known).

🌍 Equality, Diversity and Inclusion Information

Staffordshire Police is committed to understanding and engaging with all members of our communities. 🤝

Would you support Staffordshire Police collecting diversity data to help us better understand and serve our communities?

☐ 👍 Yes
☐ 👎 No
☐ 🤐 Prefer not to say

👥 Ethnicity (optional)

☐ White British
☐ White Irish
☐ Any Other White Background
☐ Mixed / Multiple Ethnic Groups
☐ Asian / Asian British
☐ Black / Black British
☐ Arab
☐ Any Other Ethnic Group
☐ Prefer not to say

📞 Further Contact

☐ ✅ I am happy to be contacted if further information is required.

🙏 Thank You

Thank you for taking the time to complete this form. Your feedback is important and helps us work with the community to address local concerns and improve neighbourhood safety. 🏘️💙

👮 Neighbourhood Policing Team

📨 Return via: Reply message or hand directly to the officer where appropriate.

🔒 Once any reported issues have been recorded on our systems, this completed form will be securely destroyed in accordance with data protection requirements.

📱 SmartAlert

🔔 Would you or someone you know like to receive local policing updates and community alerts?

If so, please provide the details below and we can assist with registration.

👤 Name: ___________________________________________

🏠 Address: _________________________________________

📧 Email: ___________________________________________

📞 Telephone Number: ________________________________

🤝 Working Together for a Safer Community

Thank you for supporting your local Neighbourhood Policing Team. 🚔💙🏡