SPOON Sexual Exploitation, Abuse, and Harassment Anonymous Complaint Form
Part I — Information About Victim
Name of victim:
*
Name
Address of victim:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email address of victim:
example@example.com
Phone number of victim:
Please enter a valid phone number.
Format: (000) 000-0000.
Age of victim:
Age
Sex of victim:
Sex
Name(s) of parent(s), if victim is under age 18:
Name(s)
Address of parent(s), if victim is under age 18:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email address of parent(s), if victim is under age 18:
example@example.com
Phone number of parent(s), if victim is under age 18:
Please enter a valid phone number.
Format: (000) 000-0000.
Has the victim given consent to the completion of this form?
*
Yes
No
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SPOON Sexual Exploitation, Abuse, and Harassment Anonymous Complaint Form
Part II — Details of Incident
Date of incident:
*
-
Month
-
Day
Year
Date
Time of incident:
*
Time Minutes
AM
PM
AM/PM Option
Location of incident:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Brief description of incident:
*
Physical and emotional state of the victim: (Describe any cuts, bruises, lacerations, behavior, and mood)
*
Name of witness:
*
Name
Address of witness:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email address of witness:
example@example.com
Phone number of witness:
Please enter a valid phone number.
Format: (000) 000-0000.
Name(s) of parent(s), if witness is under age 18:
Name(s)
Address of parent(s), if witness is under age 18:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone number of parent(s), if witness is under age 18:
Please enter a valid phone number.
Format: (000) 000-0000.
Email address of parent(s), if witness is under age 18:
example@example.com
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SPOON Sexual Exploitation, Abuse, and Harassment Anonymous Complaint Form
Part III — Details of Accused Persons
Name of accused persons:
*
Name
Nationality of accused persons: (If nationality is unknown, put “unknown”)
*
Nationality
Address of accused persons:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email of accused persons:
example@example.com
Phone number of accused persons:
Please enter a valid phone number.
Format: (000) 000-0000.
Age of accused persons:
Age
Sex of accused persons:
Sex
Name(s) of parent(s), if accused persons is under age 18:
Name
Address of parent(s), if accused persons is under age 18:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email address of parent(s), if accused persons is under age 18:
example@example.com
Phone number of parent(s), if accused persons is under age 18:
Please enter a valid phone number.
Format: (000) 000-0000.
Job title(s) of accused persons:
Job Title
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SPOON Sexual Exploitation, Abuse, and Harassment Anonymous Complaint Form
Part IV — Follow Up Questions
Have the police been contacted?
*
Yes
No
Unsure
If yes, what happened? (Put "N/A" if not applicable)
*
If no, does the victim want police assistance, and if not, why? (Put "N/A" if not applicable)
*
Has the victim been informed about available medical treatment?
*
Yes
No
Unsure
Has the victim sought medical treatment for the incident?
*
Yes
No
Unsure
If yes, who provided treatment? What is the diagnosis and prognosis? (Put "N/A" if not applicable)
*
What immediate security measures have been undertaken for the victim?
*
Who is responsible for ensuring the security measures for the victim going forward? (If unknown, put “unknown” in name field)
*
Name
Title and organization for who is responsible for ensuring the security measures for the victim going forward? (If unknown, put “unknown” in name field)
*
Title & Organization
Details on legal, medical, and psychological needs of the victim going forward:
*
Decisions and actions requested from headquarters:
*
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SPOON Sexual Exploitation, Abuse, and Harassment Anonymous Complaint Form
Part V — Information About Complainant (OPTIONAL)
The complainant does not have to provide any personal information but may do so on this page if desired. If the complainant would like to remain anonymous, please go down to the bottom and press "submit" to complete this form.
Name of complainant:
Name
Address of complainant:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email address of complainant:
example@example.com
Phone number of complainant:
Please enter a valid phone number.
Format: (000) 000-0000.
Age of complainant:
Age
Sex of complainant:
Sex
Name(s) of parent(s), if complainant is under age 18:
Address of parent(s), if complainant is under age 18:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email address of parent(s), if complainant is under age 18:
example@example.com
Phone number of parent(s), if complainant is under age 18:
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Should be Empty: