Subject

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This Incident Reporting Form is to be used for reporting concerns about incidents and people involved at CLAW in a semi-anonymous manner as the information provided on this form will be reviewed by the Incident Response Team and incidents reported will be addressed on a case-by-case basis.

An incident could be conflict of any kind, including, but not limited to, harassment, a consent issue, a misunderstanding, an argument, bullying...

Utilizing the Incident Response Form and/or meeting with the Incident Response Team is a voluntary process. Because free flow of communication is so critical, information shared on this Incident Reporting Form and discussions in an Incident Response Team session are privileged and/or confidential. Any shared information will be treated with confidentiality and respect and shared only as needed to provide the assistance you have requested.

Keep in mind that limits can be violated deliberately or through poor communication, misunderstandings, lack of knowledge, accidents, and/or lack of experience. Be assured, the Incident Response Team are not here to judge and all information reported is taken seriously.

If you have an immediate health or safety concern, please seek medical assistance (Urgent Care, Hospital ER, or call 9-1-1 depending on the immediacy and severity of your emergency) or law enforcement assistance (Non-Emergency 216-621-1234, Emergency 9-1-1).

Please provide as much information as you are comfortable to allow us to provide you with the best safety, support, and/or referrals:

What is the concern you would like to share? (Please describe the incidentand be as specific as possible, including names, dates, times, and locations.)(*)

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What actions were taken before and after the incident…

By you?

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By the other party/ies

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If you have a photo of involved parties, you may upload it here. We ask that you do not further engage individuals in order to obtain a photo for this purpose.

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Did you seek, or do you plan to seek, medical care for any injuries related to this incident?(*)

Yes

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If you answered YES above, can you please provide a brief statement about the medical care received?

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Was alcohol and/or drugs used before or during the incident?

Yes

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If you answered YES above, please provide a list what drugs/alcohol was used. (This information is intended to help us better support you.)

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Do you have a history of any kind with the individual/s involved, either directly or through another person (former partner, pack member, etc.)?(*)

Yes

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If you answered Yes above, Please explain the history.

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If there are public records relating to your concern, please provide information on what has been documented, where it is available and any pertinent case number(s).

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How would you like to proceed? Have the Incident Response Team...(*)

No further action is required. I am reporting for the purpose of informing and data collection.

Talk with you personally regarding this concern via email, phone, or text.

Investigate further by speaking separately with you and the other parties involved (if other parties can be contacted).

Facilitate a discussion between all parties involved in an attempt to resolve the concern via conference call (if all parties can be contacted).

Other (Please let us know below)

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If you selected Other above, please let us know how you would like to proceed

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Meeting with the Incident Response Team will be in a quiet area that provides a safe, comfortable space with a reasonable expectation of privacy.

If there are specific things you do NOT want us to mention to the other parties involved, please tell us about it here.)

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We may have further questions about this Incident Report, which would require being able to contact you. Additionally, if you have indicated you would like a meeting, investigation, facilitation, etc. regarding this concern, please provide contact information you would like us to use below.

How may we contact you?(*)

Call

Text

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Phone

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Please let us know your email address.

Name we may use when contacting you(*)

Please let us know your name.