OCIC INCIDENT REPORTING FORM - REPORTING ON BEHALF OF A SURVIVOR
Please use this form if you have received a disclosure of sexual exploitation, abuse and harassment by anyone involved with OCIC, 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. The incident report should 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. If you are reporting on behalf of a survivor with their consent, please write a clear record of what is said by them in their own words, and allow them to read what you have written. If they are not able to read your report themself, please read the text to them and then ask them to verify if they are satisfied with what you have written. If they are not, please correct the text with them and then verify again. Please note that response to any of the following questions is optional, if you wish to remain anonymous.
Information of the person reporting an incident on behalf of a survivor
Name of person reporting an incident on behalf of a survivor
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
Survivor information
Name of Survivor
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)
Has the survivor given consent to the completion of this form?
Yes
No
Unsure
How does the survivor prefer to be contacted, if at all?
Name(s), Phone Number and Address of Parent/Guardian, if the survivor is 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 of the survivor (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)
Has the survivor been informed of available medical care?
Yes
No
Unsure
Has the survivor sought medical treatment after the incident?
Yes
No
Would the survivor like any assistance contacting medical care?
Yes
No
Has the survivor contacted the police?
Yes
No
Would the survivor like any assistance contacting the police?
Yes
No
Has the survivor contacted legal services?
Yes
No
Would the survivor like any assistance contacting legal services?
Yes
No
What immediate security measures have been undertaken for the survivor?
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 the survivors’ 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: