Safety Incident Report Form
This is the place to report an incident relating to safety and consent issues that occurred at or relates to Dance Church Minneapolis. All responses and personal information will be kept confidential within the Safety & Care Team. A member of our team will follow up as soon as possible to seek collaborative resolution.

Important, Please Read:
The following options are available in filling out this form...
  • You may fill this report out yourself, with your own contact information or an alias (to protect your identity). We will refer to you with this alias, and follow up with you directly via the contact method you prefer.
  • You may have a trusted advocate fill this out on your behalf, and select them as our point of contact for our team to follow up with. This person can act as a liaison between us.
After reading the report information, consulting appropriate resources, and connecting with you or your advocate - we will collaborate together to develop and implement the best possible response measures.

Thank you for taking the time to report this incident.

If you are in need of immediate support
  • Suicide Hotline: Call or text 988
  • National Sexual Assault Hotline: call 1-800-656-4673 or chat at www.Rainn.org
  • Domestic Violence Hotline: 1-800-799-7233
  • Immediate Mental Health Support: call 1-855-927-6546 or text "support" to 85511
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Are you submitting this on behalf of yourself or another?
 *
Your Name 
(or alias, if you'd like your identity to remain anonymous to our team)
 *
Your or our advocate's email address?
Your or your advocate's phone number?
Preferred method of contact?
Clear selection
Date of Incident *
MM
/
DD
/
YYYY
Please describe the incident in as much detail as possible, to an extent you feel comfortable sharing with our team.
 *
Name or identifying information of the person who caused harm, crossed boundaries, and/or acted inappropriately towards you.
Is there anything else about this instance or person you'd like to mention?
How can we best support you?
We follow up on every report we receive to collaborate on actions to best support you. 
Do we have your permission to contact you/your advocate? If so, write, yes below.

If you have a specific needs relating to how or when we contact you, let us know that. 
For example "I need 1 week before anyone reaches out to me".
 *
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