Report Form
As a company, WeBreak takes allegations of abuse very seriously and are committed to responding to such incidents in a prompt, supportive, and appropriate manner. Please use this form to report any suspicious behavior, inappropriate behavior, and/or abuse and molestation incidents. If possible, a report should be completed within 24 hours of the event.
Date of Report:
*
-
Month
-
Day
Year
Date
Back
Next
Information of Reporter
Reporter's Full Name
*
First Name
Last Name
Reporter's Phone Number
*
-
Area Code
Phone Number
Reporter's Email
*
example@example.com
Back
Next
Information of Person Involved
Is the involved person under 18 years old?
*
Yes
No
Full Name (person under 18 years old)
*
First Name
Last Name
Full Name (legal parent or guardian if under 18)
*
First Name
Last Name
Phone Number (legal parent or guardian if under 18)
*
-
Area Code
Phone Number
Email (legal parent or guardian if under 18)
*
example@example.com
Back
Next
Incident Details
Date of Incident:
*
-
Month
-
Day
Year
Date
Time of Incident:
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Location of Incident:
Please provide a detailed description of the incident:
*
Please upload any photos or videos (if applicable)
Browse Files
Cancel
of
Back
Next
Injuries
Was anyone injured?
*
Yes
No
If yes, describe the injuries:
*
Please upload any photos or videos (if applicable)
Browse Files
Cancel
of
Back
Next
Witnesses
Were there witnesses to the incident?
*
Yes
No
If yes, enter witnesses' names and contact information:
*
Back
Next
Police / Medical Services
Were police notified?
*
Yes
No
If yes, was a report filed?
*
Yes
No
Was medical treatment provided?
*
Yes
No
Refused
Not Applicable
If yes, where was medical treated provided?
*
On Site
Hospital
Other
Back
Next
Person Filing Report
Signature
*
Print Name
*
Date
*
-
Month
-
Day
Year
Date
Submit
OFFICE USE ONLY
Report received by:
Date received:
-
Month
-
Day
Year
Date
Follow up action taken:
Should be Empty: