Member Incident Report
Your Name
Your answer
Member you are making complaint about:
Your answer
Date of Incident:
MM
/
DD
/
YYYY
Type of incident
Please check all that apply!
What role do you want MCCC to play?
Boundary Violations
In case of a boundary violation (if inapplicable, skip to the next section):
How were your boundaries crossed?
Your answer
Did you feel physically unsafe?
Did you feel emotionally unsafe?
Did you know your boundaries before they were crossed?
(many people only figure this out afterwards)
Did you clearly articulate your boundaries before and/or after they were crossed?
Were you able to let the person know what they did (direct communication)?
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