AAO Code of Conduct Incident Reporting Form

American Academy of Osteopathy Incident Reporting Form

Please use this form to report a suspected violation of the AAO Code of Conduct.
AAO Code of Conduct Incident Reporting Form

This form is designed to be used by American Academy of Osteopathy members or those attending an AAO sponsored or related event. This form may be completed by any person who witnesses or is subject to an incident that they reasonably believe is a violation of the AAO Code of Conduct. All information submitted is considered confidential and will only be utilized by our team to respond to an incident. Please note that information provided will be used to investigate a reported incident.
Please Enter Your Name Here*

First NameLast Name

Please provide an email where we can contact you for follow up*
example@example.com
Phone Number*
Please enter a valid phone number where we can contact you.
Date of Incident*

MonthDayYear
Please provide the approximate date and time of the incident that you are reporting.
Hour MinutesAM/PM Option

Incident Information

In this section, we will gather information about the incident, the parties involved, and the location. Please provide as much information as you can. If you do not know an answer, please type "unknown" or "NA"
General Nature of the Event*

Harassment/BullyingInappropriate statements or actionsInappropriate/unwanted sexual comments or advancesAssault or unwanted physical contactOther
What is your role in this event?*

Subject - I was a party involved in this incidentWitness - I observed this incident as it occurredThird Party - I was not directly involved in this incident, but it was reported to me.
Subject Name (This is the person who was the target of the violation)*

Subject First NameSubject Last Name
Actor Name (This is the person who committed the violation)*

Subject First NameSubject Last Name
Other parties involved
Please type the names and roles of any other involved parties. For example, if there is more than one subject, you would type "Name, Subject". For a witness, you would type "Name, Witness". If you have contact information for any of these parties, please list it after their name and role.

Did the incident occur:*

During an AAO sponsored event or meeting?During a session or event affiliated with the AAO Convocation/Annual Meeting?During a different society event or meeting?Somewhere else?
Please provide details on where the incident occurred*
For example, "During a poster session at the annual meeting", or "This is an ongoing pattern of behavior"
Was the incident reported to police or security?*

YesNoUnknown

Please provide us with as much information as possible about the incident*
This field is the narrative field for the incident. Please provide as much information about the incident as possible. Include, where known, dates, times, and locations. It is acceptable to use "Subject" and "Actor" in place of the names that you provided above. Please note that this information will be shared only with the society designated incident responder. All information provided will be kept confidential, except that which would require notification under law. If you require additional space, you may also upload your statement using the button below.
Statement/Additional information upload

If you prefer, you may upload your narrative statement as a Word or PDF document.
Cancelof
What is the preferred method for us to contact you to follow up on this incident?*

Phone callEmailOtherPlease do not contact me
Submission Confirmation

By submitting this form, I am acknowledging that the information provided is true and correct to the best of my knowledge and belief. I understand that misuse of this service or knowingly providing false information may result in civil and criminal penalties.
I,(Name) , hereby certify that the information provided is true and correct to the best of my knowledge and belief. I further acknowledge that the information provided in this form will be used to conduct an investigation and review of this incident and that I am aware that the American Academy of Osteopathy, through its designated agent, may contact the parties listed for interviews or statements.
Signature*

Clear
Should be Empty:

American Academy of Osteopathy Incident Reporting Form

AAO Code of Conduct Incident Reporting Form

Incident Information