One moment please...

Incident & Impact Report

This feedback form is for Freedom Project volunteers, staff, participants, and community members to report Concerning Incidents -- Incidents which have a harmful impact or potential harmful impact to Freedom Project participants, staff, volunteers, or the community pertaining to issues such as safe spaces, personal well-being, morale, effectiveness to fulfill Freedom Project mission/vision/values, commitment to racial equity & social justice, facility/ property, legal liabilities, and/or public image.

Form may be completed directly by concerned person or verbally reported to an Office Staff member who will transcribe the incident on this form at the time of report.

NOTE: If the Concerning Incident requires emergency attention, report to Executive Director immediately. All other feedback is to be reported at the next Office Staff Meeting.

Contact Information

Name (optional)

First Name

Last Name

Email (optional)

Verify Email

Date of Incident

Use field below if multiple dates.

Relevant Person(s)

Is this the first time you have reported this incident?

Yes (please skip questions "a" and "b")

No, I have reported this before (please answer "a")

No, I have given this feedback before but not through an official report (please answer "b")

(a) If this incident has been reported previously, please estimate date of report:

(mm/dd/yyyy)

(b) If you have given this feedback previously but not in a report, which Office Staff did you tell? And when?

Incident Description

What was the context of the incident? (setting, situation, persons present)

What did you observe? (what was seen, heard, or done)

How did you interpret this incident?

What needs and values of yours were not met? How did this incident impact you? (Emotionally, physically, other)

How would you like Freedom Project's Office Staff to respond to your report? (Given organizational and legal obligations)

Anything else you would like us to know?