Concerning Encounter Church Report Form

Date of Incident *

Approximate Time of Incident *

Location of Incident *

Please describe the incident in your own words. Include who was involved and if there were any witnesses (Name(s) or description(s), if known). *

How would you describe the encounter? *

Verbal (comments, jokes, tone)

Physical (unwanted touch, proximity)

Emotional/Intimidating

Inappropriate Behavior

Discrimination

Other

Did you feel unsafe at any point?

Yes

No

How did this experience affect you?

Did you take any action at the time? (e.g., spoke to someone, left the area): *

Yes

No

Have you reported this incident to anyone else? *

Yes

No

Preferred Method of Contact *

Phone

E-mail

In Person