Cedar Rivers Protester Form

Date of Incident

Date

Location of Incident

If you were not visiting Cedar River Clinics, please write in name of clinic or doctor you were visiting

Name

Email

Phone Number

Please tell us about your experience with protesters in your own words. Please give us details including if you were touched, bullied/harassed, forced to take literature, approached at your car, obstructed in any way, and how you felt about it (frightened, intimidated, etc).

Describe Protester(s)

Describe Their Sign

What group did the protester(s) say they were with?

Would you like to be contacted by our security team to lodge a complaint?

YesNo

Are you willing to share your experience publicly?

YesAnonymouslyNo

Please be sure to fill out contact info if you would like your experience shared or to be contacted by security.

Patients’ safety and well-being is important to us. Thank you for taking the time to share your experience!

Please verify that you are human*