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ACRL Intake form
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* Indicates required question
Name
*
Your answer
Email Address
*
Your answer
Phone Number
Your answer
How would you like to be contacted?
*
Email
Phone
What type of incident are you reporting
*
Discrimination
Harrasement
Racism
Other:
Date of Incident
*
Your answer
Location of the Incident
*
Your answer
Describe what happened
*
Your answer
Personal Impact (how did it affect you personally)
*
Your answer
Have you reported this incident to any other organization or authority?
Yes
No
Clear selection
If yes, please provide details of previous reports, including dates and outcomes.
Your answer
What resolution or outcome are you seeking?
Legal
Mediation
Apology
Advocacy and Support
Other:
Clear selection
Submit
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