G.O.D.S. Safety Team Report Form

Use this form to provide full details of the incident. This is for the purposes of record keeping and response procedures. Please fill out everything you can and provide as much detail as possible. If you wish to remain anonymous, report your name as "Anonymous" and leave the contact information portion blank. Anonymous submissions will be kept as a record of the complaint, but we may not be able to take an action.

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* 1. Please describe the incident and all those involved, including names if possible.

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* 2. Please provide the names and contact information (if known) of any witnesses present at the time of the incident.

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* 3. Today's Date

Date

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* 4. When did the event happen? Leave this question blank if it's same as today's date.

Date of Event

Date

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* 5. Did you take any action or address the concern on your own (e.g. verbal/nonverbal suggestions to modify behavior, previous complaints filed) and how did they respond to your action?

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* 6. Is anyone involved in the safety concern a minor?

Yes

Unsure/Don't Know

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* 7. Do you wish to have your name withheld from the person you're reporting?

Yes

Other (please specify)

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* 8. What is your name? If you wish to remain anonymous, report your name as "Anonymous" and leave the contact information blank. Anonymous submissions will be kept as a record of the complaint, but we may not be able to take action.

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* 9. Preferred method of contact. Please fill in the correct information to boxes which are checked.

Phone Call

Text Message

In Person at Next Dance (Please provide the date of the next GODS dance that you will be attending)

Other

G.O.D.S. Safety Team Report Form

Question Title

* 1. Please describe the incident and all those involved, including names if possible.

Question Title

* 2. Please provide the names and contact information (if known) of any witnesses present at the time of the incident.

Question Title

* 3. Today's Date

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* 4. When did the event happen? Leave this question blank if it's same as today's date.

Question Title

* 5. Did you take any action or address the concern on your own (e.g. verbal/nonverbal suggestions to modify behavior, previous complaints filed) and how did they respond to your action?

Question Title

* 6. Is anyone involved in the safety concern a minor?

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* 7. Do you wish to have your name withheld from the person you're reporting?

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* 8. What is your name? If you wish to remain anonymous, report your name as "Anonymous" and leave the contact information blank. Anonymous submissions will be kept as a record of the complaint, but we may not be able to take action.

Question Title

* 9. Preferred method of contact. Please fill in the correct information to boxes which are checked.

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* 10. Specify the appropriate contact info.