CASA Incident Form
This form should be filled out when you have a concern about something that happened to you or someone you know. Situations such as discrimination, harassment, intimidation, and assault are very serious and should be addressed and escalated to someone who can help.

You are by no means required to use your name, but please do if you would like someone to follow up with you. We will do our best to handle each situation quickly, sensitively, and confidentially.

This form should not be used for any emergencies that require immediate attention. Instead, please contact the police or call 911.

Alternatively, if you don't feel comfortable submitting a form, you can contact the CASA VP Internal Affairs at elinor.shpigel@casajmsb.ca directly. 

Here are some additional resources that can help you if needed!

Sexual Assault Resource Center (Concordia): 514-848-2424 ext. 5972
Campus Security: 514-848-3717
Montreal Sexual Assault Crisis Line: 514-933-9007
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Name
If you prefer not to enter your name, please type X.
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Where did this happen?
Ex: On/off campus event, Classroom, Bathroom, Internet, Parking lot

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Describe what happened.
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When did this happen?
 *
MM
/
DD
/
YYYY
Who was involved in the situation?
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Did anyone witness what happened?
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If yes, who and do we have your permission to contact them?
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Describe if it was a one-time incident or part of an ongoing problem.
Describe any injury incurred from the incident(s).
This can be mental or physical. If you prefer not to give a description, please type X.

How would you prefer we help you with this situation?

Can we contact you to ask further questions about the incident?

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