BROOKLYN MAQAM INCIDENT REPORT FORM
Please use this form to report any incident that you would like to bring to the attention of Brooklyn Maqam's organizers
Name
*
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Date incident took place
*
-
Month
-
Day
Year
Date
Date Incident Reported (if different from date incident took place):
-
Month
-
Day
Year
Date
Time Incident took place
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
May we contact you about this incident? If so, please provide your email address
*
Yes
No
Provide your email address below
Person(s) involved in incident:
*
Brooklyn Maqam Staff
Artist performing at a Brooklyn Maqam event
Patron/Audience member
Venue staff
Other
Name(s) of person(s) involved:
*
Location of incident
*
Do you feel this incident occurred based on any of the following? Please provide details in the incident description below.*
*
Age
Stolen Property
Ethnicity
Gender Identity and/or expression
Race/Color
Sexual Harassment
Sexual Orientation
Physical Attack
Sexual Assault
Stalking
Verbal Attack
Other
Please provide a detailed description of the incident using specific and concise language:
*
Please indicate Brooklyn Maqam staff who were alerted about this incident prior to this report:
*
Please indicate if any of the following were alerted about this incident:
Law Enforcement
Venue staff
Emergency Medical Staff
Other
What happened to involved party/parties:
First Aid Administered
Refused Treatment/Transport
Transported to Hospital
Went home
Unknown
Other
Any additional information:
Submit
Should be Empty: