STL Jitterbugs Safe Spaces Incident Report Form

This form is available for anyone in the St. Louis Jitterbugs community to use to report an incident in which they feel their safety (physical or emotional) was threatened.

On what date and at approximately what time did this incident occur? *

YYYY

Time

As clearly as possible, please describe the incident that occurred. Please include as much relevant information (names of parties involved, location, witnesses) as you are comfortable sharing. *

Your answer

In reporting this incident to the St. Louis Jitterbugs, what is your ideal outcome? (check all that apply) *

I don't want any action to be taken; I just want to put this issue on the radar.

I would like someone from the St. Louis Jitterbugs to talk with the person who made me feel uncomfortable, but I don't want my name or specific details from this report to be used in that process.

I would like someone from the St. Louis Jitterbugs to talk with the person who made me feel uncomfortable and am okay with my name and specific details from this report to be used in that process.

I want someone from the St. Louis Jitterbugs to work with me to talk with the person who made me feel uncomfortable.

Other:

Required

Name

(If you would like to be contacted for follow up)

Your answer

Email address

(If you would like to be contacted for follow up)

Your answer

Phone number

(If you would like to be contacted for follow up)

Your answer

Submit

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