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?
MM
/
DD
/
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)
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
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