Kiez Burn Harm Reporting
This form collects information regarding possible Kiez Burn Code of Conduct violations. To file a report with the Kiez Burn Radical Accountability Division (RAD), please fill out and submit this form. If the report warrants an investigation, RAD will assigning your case to a team of two RAD members who will contact you about the next steps. 

All information shared in this form will be treated confidentially and is accessed only by the RAD members. You can find a list of RAD members and more information about the RAD's work on Kiez Burn website: https://mmm.kiezburn.org/rad. If you have a strong reason for withholding information from a particular RAD member you can leave a contact request to our email rad@kiezburn.org. Please mention who you would like to contact you. 

Please note: the RAD does not offer mental health or legal counselling. If you have experienced harm or are in crisis situation please see the list of support resources we have collected: Rad List of Support Resources

How we work?
Sign in to Google to save your progress. Learn more
Your Name
Report anonymously *only* if you do not wish to have any follow up. Anonymous information can be useful when it contains verifiable facts but information with no contact information is, by its nature, of limited value in our process.
What are your pronouns 
What is your email address?
If you wish to be contacted by the RAD team please provide us your email address. We will use your email only to contact you about the case you are reporting. 
What is the nature of harm / violation that you wish to report? *
Who are you are reporting? 
You can give us any information that helps us identify the person. You can also leave this empty if you rather discuss that detail in person. 
How is the person connected to the Kiez Burn Community?
For example, has the person attended Kiez Burn festival or other KB up events and/or related burner events, or other burn events inside or outside the local community?
Please note the date and time, if possible, when the incident took place. *
If you're reporting several instances, please enter a time range and note any specific instances in the narrative.
Where did the incident or incidents take place? *
Were bystanders present when the incident(s) occurred?
If yes, please specify if you are acquainted with them should the investigators need to reach out to them with your approval. Include email addresses if possible and appropriate. We will not contact anyone without discussing the case with you first.
Basis of Complaint
Please describe the incident(s) to a level that is comfortable for you. Details can also be discussed in a meeting if you don't want to share them in writing. 
The Conflict Awareness team seeks your intention for filing this report.
Confidentiality *
All information shared in this form will be treated confidentially and is accessed only by the Kiez Burn Radical Accountability Division (RAD) members. If you have a strong reason for withholding information from a particular RAD member please do not use this form, but email us a contact request and let us know who you would like to contact you.
Required
GDPR Disclaimer: *
I consent to my data being stored for a period of up to 36 months from the last date my data was entered or modified, and for it to be used only to facilitate the scheduling and safety of volunteers on behalf of Kiez Burn. I understand that you will delete my data within one month of my giving formal written notice to the registered address of Kiez Burn, asking you to do so.
Required
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms