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Anti Harassment Reporting Form

Incident Reporting Form

This form should be completed and submitted as soon as possible after learning of an incident that may violate the ASA Anti-Harassment Policy.

Please answer all questions as thoroughly as possible. If you do not know an answer to a question, please write “Unknown.” If a question may not apply, write “N/A.”

  • (If you would like to list your name and/or have a member of the ASA team contact you)
  • MM slash DD slash YYYY
  • Please provide more information about the location.
  • If you know, or feel comfortable listing the name(s) of the alleged violator(s), please list it here.
  • If you do not know, or do not feel comfortable listing the alleged violator’s name(s), please list any identifying factors you can here.
  • Do you currently have, or have had, a relationship of any kind with the perpetrator(s)? If so, please indicate the type of relationship here.
  • Note: an email copy of your report can only be shared with you if you provide your email address above.
  • For Completion by ASA Only