Report of Misconduct

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Offender Information

This section is about the individual you are reporting. Please provide as much information as possible.

Offender Name *

Gender

Phone 1

Position(s) this individual holds or held *

Organization where individual works and/or volunteers or where the individual worked/volunteered previously

Address Line 1

Address Line 2

City

State/Province

Zip/Postal Code

Country

Incident Information

This section asks questions about the incident or incidents you are reporting. Please provide as much specific information as you are able.

Type of offense (what happened?) *

Where did the incident(s) take place? (city, state and any other location information) *

Please Describe what happened: (Including... Who, What, When, Where) *

Victim Information

This section is for information about the victim or victims. If you are the victim and wish to remain anonymous, you may do so. In that case, please enter only your age, city, state, and chapter affiliation (ie: DREAM)

Victim Name

Age or approximate age *

Chapter/Organizational Affiliation (if any):

Contact phone number (Note, if this person is under 18, please provide contact information for his/her parent or guardian):

Contact Email address (if this individual is under 18, please provide contact information for parent or guardian):

Gender

Reporter's Information

You may remain anonymous if you wish. However, providing your information is vastly helpful to a swift and effective investigation. A person reporting alleged misconduct should not fear any retribution and/or consequence when filing a report he or she believes to be true.

Name

Phone Number

Email Address

Chapter Affiliation (if any)

Relationship to victim

Other information: If you have any other information that you feel would be helpful to an investigation of the alleged offense you have reported, please enter it here: *

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Report of Misconduct