OCIC INCIDENT REPORTING FORM - REPORTING AS A SURVIVOR
Please use this form if you have experienced an incident or incidents of sexual exploitation, abuse and/or harassment while engaged in the activities of the Council. Gathering information regarding an incident or incidents of sexual exploitation, abuse and harassment is a critical element of the reporting process. We ask that this incident report be objective and precise, focusing on the facts and relevant information. Incident Report Forms are sent directly to the Executive Director and/or Chair of the Board of Directors when submitted from the website. Please note that your response to any of the following questions is optional, if you wish to remain anonymous.
Name
First Name
Last (Family) Name:
Age
Gender
Woman
Man
Transgender
Non-binary
Choose not to respond
Phone number
Address
Title/Position(s) held (if applicable)
Organization (if applicable)
How do you prefer to be contacted (if at all)
Name(s), Phone Number and Address of Parent/Guardian, if you are under 18 years of age
Incident details
Date of incident
-
Month
-
Day
Year
Date
Time of incident
Location(s) of incident
Brief description of incident
Physical and emotional state (describe any cuts, bruises, lacerations, behaviour and mood)
Were there any witnesses
Yes
No
Unsure
Witness(es) Name(s), Phone Number, Address and email (if applicable)
Have you been informed of available medical care?
Yes
No
Unsure
Have you sought medical treatment after the incident>
Yes
No
Would you like any assistance contacting medical care?
Yes
No
Have you contacted the police?
Yes
No
Would you like any assistance contacting the police?
Yes
No
Have you contacted legal services?
Yes
No
Would you like any assistance contacting legal services?
Yes
No
What immediate security measures have you undertaken or have been undertaken to support you?
What other support would you like OCIC to provide at this time, if any?
Information about the alleged perpetrator(s) (if known)
Name
First Name
Last (Family) Name
Age
Gender
Woman
Man
Transgender
Non-binary
Choose not to respond
Phone number
Address
Title/Position(s) held (if applicable)
Organization (if applicable)
Relationship to you
Physical description
Consent to be contacted
OCIC does not tolerate sexual exploitation, abuse and harassment and has a duty of care to ensure that everyone engaged with the Council is treated with dignity and respect, regardless of identity, and is able to safely and equitably access OCIC. We are committed to upholding a survivor-centered trauma informed response to survivors, and will provide referrals to support services that can offer comprehensive quality assistance and support in line with your wants and needs. Assistance will be made available regardless of whether a formal internal response or investigation has been concluded.
*
I consent to OCIC contacting me for further support.
I do not consent to OCIC contacting me for further support.
I consent to this Incident Report being submitted to the
*
OCIC Executive Director AND Chair of the Board of Directors
OCIC Executive Director ONLY
OCIC Chair of Board of Directors ONLY
Thank you for submitting this Incident Report.
Submit
Should be Empty: