Earthaven Incident Report form

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Thank you for taking the time to report about your experience and/or concerns here. Your feedback is important to us. If you would prefer to report in person, please contact a member of the Consent Culture Team. If you are in need of immediate support or intervention, please feel free to contact a member of CCT, or anyone you feel comfortable with.
consentculture@earthaven.org
Earthaven Consent Culture Team:
Kaitlin (828-779-8850, kaitlinilya@gmail.com)
Rachel (828-669-0997, atinyseed@gmail.com)
Julia (804-516-8880, julia.millar@gmail.com)
Lyndon (828-664-0067, lyndonwattermonkey@gmail.com)

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Confidentiality

This report will be received by the Earthaven Consent Culture Team. Know that it is voluntary to include your name and contact information, and that anonymous and/or private reporting is possible. We are committed to upholding your desired privacy and level of confidentiality and to follow the lead of your requests in this regard. This report will be shared with at least two members of the Consent Culture Team, whose current members are: Kaitlin Lindsay Johnston, Rachel Fee, Lyndon Felps and Julia Taylor.

Who on the Consent Culture Team do you consent to viewing this report? Please choose at least two.

Any/all

Kaitlin Lindsay Johnston

Rachel Fee

Lyndon Felps

Julia Millar

Other:

Your name (optional)

The Incident(s)

We acknowledge that this may be challenging to write about, and we are grateful that you are stepping forward.

Date(s) or time-frame of the Incident(s)

Location of the incident(s) (if applicable)

Description of the Incident

Please describe the situation you are reporting or giving feedback about. If this includes a specific violation or harmful behavior, please include the basics of what happened, who was involved, any subsequent action taken and any other information that you would like us to know.

Next Steps

At this time, would you like to initiate a formal or informal conflict resolution procedure regarding this issue? *

yes, I would like to initiate a formal resolution procedure at this time

yes, I would like to initiate an informal resolution procedure at this time

No, I would not like to initiate a resolution procedure at this time

Maybe. I would like more information about the options

Other:

What next steps, if any, would you like to be taken and what role would you like to take (or not take) in those steps? What, if any, requests do you have of Consent Culture Team regarding next steps?

If you do not want to initiate next steps at this time, would you like to be or are you willing to be contacted regarding this report? *

Yes, please contact me. I need support.

Yes, willing, but I am not in need of support at this time.

No, do not contact me at this time. I will be in touch if I change my mind.

Yes, but only to send me resources you have for supporting myself through this process.

Other:

If yes, what is your preferred way(s) for us to contact you (optional)

Anything else you want us to know?

Thank you so much. If you have any questions or want to speak with a Consent Culture Team member, please contact us at consentculture@earthaven.org or contact any of us privately.

Earthaven Consent Culture Team:
Kaitlin (828-779-8850, kaitlinilya@gmail.com), Rachel (828-669-0997, atinyseed@gmail.com),
Julia (804-516-8880, julia.millar@gmail.com), and Lyndon (828-664-0067, lyndonwattermonkey@gmail.com)

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