Musical Empowerment - Suspected Violation of Child Protection Policies Reporting Form
If this is an emergency, please call 911 and ask for the on-call social worker.

If you would like to talk to a Musical Empowerment Staff Member, call 919-891-4383.

This form can be anonymous if you choose and will be reviewed by a member of Musical Empowerment National Staff. Thank you for your dedication to protecting Musical Empowerment students.

Para español: https://goo.gl/forms/4YqcPsETTyS1hmlN2
Date of incident/observation *
MM
/
DD
/
YYYY
Time of incident/observation *
Time
:
Location of incident/observation *
Your answer
Child/Adults involved (full names if possible) *
Your answer
Description of scene/observations made that raised concern (Include: who was involved and what they were doing) *
Your answer
Other previous indicators or observations if known
Your answer
Your name or other witnesses (not needed if you wish to remain anonymous)
Your answer
Your contact information - phone/email (not needed if you wish to remain anonymous)
Your answer
Other actions taken (Were the police, social services, or other groups informed?)
Your answer
Submit
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