Concern & Incident Report Form

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RVA Zouk Movement (RVAZM) is committed to providing a safe, supportive, inclusive and educational environment for all to experience the joys of learning and practicing Brazilian Zouk. If anyone raises a concern or has made you uncomfortable at any of our events, we encourage you to tell us about it here. No incident is too big or too small. We are committed to creating an environment of accountability amongst all community members. Reporting builds awareness, strengthens our community and empowers others to do the same.

**Interpersonal Conflicts: As a community, we strive to assume good intent, treat each other with respect, and hold each other accountable. We expect individuals to manage their own interpersonal conflicts when they arise, but we encourage participants to inform us of any repeated inappropriate behaviors that may affect the community.**

All of your answers will be held strictly confidential to the RVAZM Community Safety and Wellness Team unless you give explicit consent otherwise. We are so sorry that you had a negative experience and thank you for your courage to share.

What do you wish to report? *

Safety Concern

Hygiene Concern

Sexual Misconduct

Discrimination

General Concern

Other:

Your Name (Optional):

Your name will remain confidential unless you give explicit consent otherwise. However, we respect your decision if you wish to report anonymously. Please note that if you ask us not to use your name or you do not give us your consent to take further steps, we may not be as able to manage the issue effectively.

Preferred method of contact:

For example: Facebook Messenger (Profile Link) or Call/Text (123-456-7890)

What is the First and Last Name of the person you wish to report? If there are multiple people, please include all of their names here. *

Link to this person's social media profile (Optional):

Please describe the incident that occurred, including all relevant information and as much detail as you are able and willing to provide. *

Please include: who was involved; where it occurred (class, social, another dance event, casual hangout, etc.); if you have shared this with and/or sought help from anybody else; if you have had previous negative experiences with this person; if you have spoken with the person or intend to; etc.

How can the RVAZM Community Safety and Wellness Team best advocate for you? *

The decision whether to give your consent remains your choice at all times. Please note that if you ask us not to use your name or you do not give us your consent to take further steps, we may not be as able to manage the issue effectively. This can lead to us not taking any action in some situations.

I just want you to know about the incident. No action or follow up is needed.

I would like to speak with someone on the RVAZM Community Safety and Wellness Team about this privately.

I would like for you to have a conversation with the individual(s) about my reported incident. You may use my name in the conversation.

I would like for you to have a conversation with the individual(s) about my reported incident. I wish for my name to remain anonymous when you have this conversation.

Other:

Required

Is there anything else you wish to add?

Please know that RVA Zouk Movement takes safety, discrimination, harassment or abuse of any kind very seriously. By clicking "Submit," you agree to the following: *

I acknowledge and understand that issues regarding safety, discrimination, harassment or abuse should be taken seriously.

I confirm that the details provided in this form are true and accurate to the best of my knowledge.

I am reporting the incident with the sole intent of helping keep our dance community a safe place for everyone.

I understand that RVAZM reserves the right to address misconduct in a manner appropriate to the extent of the misconduct in a variety of ways ranging from taking no action to temporary or permanent ban from future activities.

Required

Submit

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