diff --git a/report-issue/index.php b/report-issue/index.php
index 30fe3d8..0557a98 100644
--- a/report-issue/index.php
+++ b/report-issue/index.php
@@ -16,6 +16,26 @@
 
   <body>
 
+   <?php
+   // define form variables and set to empty values (or to the UA)
+   $subject = $detail = "";
+   $ua_str = $_SERVER["HTTP_USER_AGENT"];
+
+   if ($_SERVER["REQUEST_METHOD"] == "POST" ) {
+     $subject = validate($_POST["subject"]);
+     $detail = validate($_POST["detail"]);
+
+     // ENTER CODE TO SUBMIT TO GITEA HERE
+   }
+
+   function validate($data) {
+     $data = trim($data);
+     $data = stripslashes($data);
+     $data = htmlspecialchars($data);
+     return $data;
+   }
+   ?>
+
     <!-- Main Content Begins -->
     <img class="titleimg" src="/assets/title/title.webp"></img>
 
@@ -23,7 +43,7 @@
 
       <p>Give as much detail as possible so we can try to fix the problem.</p>
 
-      <form action="/report-issue/submit.php" method="post">
+      <form action="<?php echo htmlspecialchars($_SERVER["PHP_SELF"]); ?>" method="post">
         Subject:
         <br>
         <input type="text" name="subject">
@@ -37,7 +57,10 @@
         collected alongside the information you provide above and will be
         posted to git.fjla.uk/fred.boniface/athena.fb-infra.uk/issues.
         <br>
-        Your user agent is: <?php echo $_SERVER["HTTP_USER_AGENT"]; ?>
+        <br>
+        Your user agent is:
+        <br>
+        <?php echo $ua_str; ?>
         <br>
         <input type="submit">
       </form>
