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.”

Name
(If you would like to list your name and/or have a member of the ASA team contact you)
First Last
I would like the ASA to contact me about my submitted report.*
- Yes
- No
Your position/title
Phone
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Incident*
MM slash DD slash YYYY
Time of Incident
Location of Incident*
Specific Location
Please provide more information about the location.
Do you know or believe you know who the person(s) responsible is/are?
- Yes
- No
Name(s) of Alleged Violator(s)
If you know, or feel comfortable listing the name(s) of the alleged violator(s), please list it here.
Identifying Factors
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.
Relationship to Alleged Violator(s)
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.
Please provide a detailed description of the incident/concern using specific, concise, objective language (Who, what, where, when, why, and how).
I would like to receive an emailed copy of the report I submitted
Note: an email copy of your report can only be shared with you if you provide your email address above.
- I would like to receive a copy of my report via email.
For Completion by ASA Only
How did you leave things with the target?
Has the target reported the incident to the police? If so, please provide details. If no information has been shared, please indicate so.
Have you shared this information with other ASA investigators? If so, please provide details. If no information has been shared, please indicate so.
Has the target requested confidentiality?
- Yes
- No
What date was this incident reported to you?
ASA rep completing this form
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Incident Reporting Form

For Completion by ASA Only