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GB Ethics: Incident Report
Please use this form to report a violation of Gracie Barra Policies, Code of Conduct, or Honor Code.
21
Questions
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1
In What Country Are You Reporting From?
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2
What Country Are You Reporting From?
*
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3
In What Country Did The Issue of Concern Occur?
*
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4
In What Country Did The Issue of Concern Occur?
*
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5
What is The Name of The Gracie Barra School The Issue of Concern Occured?
Please add the full name of the Gracie Barra School including City, State / Province, and Country
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6
What Is your relationship with Gracie Barra?
*
This field is required.
Student
Parent (or guardian)
Staff Member
Instructor
School Owner
Not a Gracie Barra Team Member
Student
Parent (or guardian)
Staff Member
Instructor
School Owner
Not a Gracie Barra Team Member
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7
Is it your wish to remain anonymous in this report?
*
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YES
NO
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8
Is it your wish to remain anonymous in this report?
Please Select
Yes
No
Please Select
Please Select
Yes
No
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9
What is Your Name?
First Name
Last Name
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10
What is your Email Address?
example@example.com
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11
What is your phone number?
Please add a phone number registered with global communication services such as Imessage, WhatsApp, or Telegram
Country Code
Area Code
Phone Number
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12
Please list the person or persons who directly engaged on this behavior
*
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Please ad first name, last name, and the role each individual plays within the team.
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13
Identify any witnesses or other individuals who may be able to provide additional details on this issue.
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14
Do you have any reasons to believe a manager or direct supervisor is involved in the issue of concern?
*
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YES
NO
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15
Do you have any reasons to believe a manager or direct supervisor is involved in the issue of concern?
*
This field is required.
Please Select
Yes
No
Please Select
Please Select
Yes
No
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16
If you can, please identify any one else within Gracie Barra who has been made aware of this Issue of Concern
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17
Please provide an accurate description of the issue of concern
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18
What is the location in which this incident took place?
*
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Please specify if it was within the premises of the school, online or anywhere else.
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19
Is this an ongoing issue?
*
This field is required.
Did it occur multiple times or only once?
YES
NO
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20
Is this an ongoing issue?
*
This field is required.
Did it happen more than once?
Please Select
Yes
No
Please Select
Please Select
Yes
No
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21
When did the issue of concern happened?
*
This field is required.
If this is an ongoing issue, please ad the date (and time, if possible) of the most recent incident
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22
How did you become aware of this issue of concern?
*
This field is required.
It happened to me
I saw It
I heard about it
Other
It happened to me
I saw It
I heard about it
Other
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23
If other, please detail how you have been made aware of this issue of concern
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24
If any persons attempted to disguise this issue of concern, please cite their names and actions to conceal it.
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25
If you have evidence or proof that supports your report, please upload it here.
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26
Please provide any additional details regarding this issue of concern that may be useful in its assessment and resolution
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