Do you currently have any unspent criminal convictions?

Select an option Yes No

Are you, as the applicant, currently aged 18 or over?

Select an option Yes No

Details of parent or guardian (full name, phone, email, address).

Was the incident reported to the Police?

Select an option Yes No

Did you fully cooperate with the Police?

Select an option Yes No

Has there been a previous application for compensation through CICA for this incident?

Select an option Yes No

We’re going to ask you for some details as the applicant.

Please add any previous names, for example a maiden name.

Do you, as the applicant have the legal capacity to make decisions for yourself when needed?

Select an option Yes No

What was your residency / nationality status when the incident happened?

Select an option A British citizen A close relative of a British citizen Ordinarily resident in the UK An EU citizen In the UK legally as a family member of an EU citizen A European Economic Area (EEA) citizen In the UK legally as a family member of an EEA citizen A member of the British Armed Forces Close relative of British Forces living together Potential victim of human trafficking in the UK Applied for asylum in the UK

We’re going to ask for some details about the incident and offender.

Incident Date (for single incidents)

If this was a period of abuse when did the abuse start? (leave blank if not applicable)

When did the abuse end? (leave blank if not applicable)

In which country did the incident happen?

Select an option England Scotland Wales Northern Ireland Somewhere Else

Where did the incident happen? Town, City, Location?

When was the incident reported to the Police?

Explain any delay in reporting the crime to the police.

Select an option The victim was under 18 The victim was unable to report the crime Other (add details below)

If there was a delay in reporting the matter to the Police please explain the reason.

Which police force is investigating the incident?

Select an option Avon And Somerset Constabulary Bedfordshire Police British Transport Police Cambridgeshire Constabulary Cheshire Constabulary City Of London Police Cleveland Police Cumbria Constabulary Derbyshire Constabulary Devon and Cornwall Police Dorset Police Durham Constabulary Essex Police Gloucestershire Constabulary Greater Manchester Police Hampshire Constabulary Hertfordshire Constabulary Humberside Police Kent Police Lancashire Constabulary Merseyside Police Metropolitan Barking Metropolitan Barnet Metropolitan Bexley Metropolitan Brent Metropolitan Bromley Metropolitan Camden Metropolitan Croydon Metropolitan Ealing Metropolitan Enfield Metropolitan Greenwich Metropolitan Hackney Metropolitan Hammersmith Metropolitan Haringey Metropolitan Harrow Metropolitan Havering Metropolitan Hillingdon Metropolitan Hounslow Metropolitan islington Metropolitan Kensington Metropolitan Kingston Metropolitan Lambeth Metropolitan Lewisham Metropolitan Merton Metropolitan Newham Metropolitan Redbridge Metropolitan Richmond Metropolitan Southwark Metropolitan Sutton Metropolitan Tower Hamlets Metropolitan Waltham Forest Metropolitan Wandsworth Metropolitan Westminster Norfolk Constabulary North Yorkshire Police Northamptonshire Police Northumbria Police Nottinghamshire Police South Yorkshire Police Staffordshire Police Suffolk Constabulary Surrey Police Sussex Police Thames Valley Police Warwickshire Police West Mercia Police West Midlands Police West Yorkshire Police Wiltshire Police Police Scotland Argyll and West Dunbartonshire Police Scotland Ayrshire Police Scotland Dumfries and Galloway Police Scotland Edinburgh Police Scotland Fife Police Scotland Forth Valley Police Scotland Greater Glasgow Police Scotland Highlands and Islands Police Scotland Lanarkshire Police Scotland North East Police Scotland Renfrewshire and inverclyde Police Scotland Tayside Police Scotland the Lothians and Scottish boarders Dyfed-Powys Gwent North Wales South Wales Royal Military Police Leicestershire Police Lincolnshire Police

What is the crime reference number?

What led to your injuries?

Select an option Physical assault Sexual assault or abuse Domestic or family violence Arson or fire-raising Terrorist attack in Great Britain Injured by an animal or vehicle Witnessing an incident Other

Briefly describe the crime in your own words - <2000 chrs

Offenders name/s if known

Do you have contact with the offender?

Select an option Yes No

Describe your contact with the offender

Other compensation

Have you as the victim ever applied for compensation in connection with any OTHER incident?

Select an option Yes No

Enter the previous CICA reference number if you made any OTHER claim in the past

Have you applied for, or received any other form of compensation or damages in connection with THIS incident?

Select an option Yes No

Tell us more about the compensation or damages already paid out in connection with THIS incident?

If no other non-CICA claim has been made for compensation, what's the reason?

We’re going to ask for some details about your injuries and treatment.

Did you become pregnant as a result of the incident?

Select an option Yes No Not Sure

Did you lose a pregnancy as a result of the incident?

Select an option Yes No Not Sure

Did you get an infection as a result of the incident?

Select an option None HIV Hepatitis B Hepatitis C Other STD Other Infection (add details below) Not Sure

We're going to ask for some details about any mental health issues related to the incident.

Did you have a disabling mental injury as a result of the incident?

Select an option Yes No

Did the disabling mental injury last for more than 6 weeks?

Select an option Yes No

Do you still have the disabling mental injury?

Select an option Yes No

Have you had any psychological treatment as a result of the incident?

No

Yes

Details of psychological treatment Where did the psychological treatment take place

We're going to ask for some details about the impact the injuries have had.

Did you have a job (full-time, part-time, freelance, seasonal or self-employed) when the incident happened?

Select an option Yes No, At School, College, Or University No, But Had Been In Regular Work For 3+ Years Beforehand No, Caring For Someone Other (add details below)

Were you incapable of working or do you have very limited capacity to work due to the injuries sustained in the incident?

Select an option Yes, More Than 28 Weeks Yes, Less Than 28 Weeks No

Briefly state how your injuries have affected your daily life

Have you paid, or will you need to pay, for any extra expenses such as care costs, modifications to your home or physical aids, as a result of the incident?

What treatment are you, or have you received for your physical injuries?

What mental health treatments have you had?

Select an option CBT (cognitive behavioural therapy) EMDR (eye movement desensitisation and reprocessing) Antidepressants Counselling Psychotherapy Other (add details below)

Other mental health treatments?

Have you finished your treatment?

Select an option Yes No

You MUST share the details of your GP or family Doctor.

Name of your GP surgery or clinic

Street address of your GP

Town your GP is located in

Postcode of your GP's surgery / clinic

Did you attend a hospital or see any other medical professionals?

No

Yes

Name of hospital/s attended Details of hospital treatment received

Additional information

Would you like to add any additional information?

Would you prefer to speak to a male or female file handler ?

Select an option Female Handler Male Handler No Preference

Acknowlegement

I agree to RAM legal Services assessing the information that I have provided with a view to assisting me in making a claim for Criminal Injuries Compensation. I agree to the legal and GDPR policies, linked below. I confirm that I understand that RAM Legal Services are an independent legal representative who are authorised and regulated by the Financial Conduct Authority.

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