The Chicago Rose Report Form

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The information you share on this form will go to our management team who will either share your feedback at our next meeting or open a case file for you and assign your investigation to a mediator that meets your preferences. If you need more immediate assistance please send an email to our general manager at chicagorosemanagement@gmail.com

Email *

What name should our team address you by and what are your preferred pro-nouns? *

Is this report being filed for a consent violation? *

Yes

Unsure

Did this event happen in the club? *

Yes

Other:

Can you remember the date this occurred (or your best guess)? *

Were there any witnesses or staff on duty during this event (please name them) *

What is another form of contact for you besides email (discord/phone/facebook)? *

Please let us know your concerns *

Is there a specific resolution you're seeking for the issue? *

Did you also fill out an incident report at the club? *

Yes

I would prefer the team member reaching out to me to identify as (check all that apply) *

No Preference

BIPOC

Latinx

LGBTQIA+

Female Identified

Male Identified

A Disabiilty Advocate

Trained In Mental Health

Other:

Required

Is there someone you would like us to ensure does not work on your investigation? *

Thank you for sharing this information with us. Our Team strives to reach out within 24-48 hours.

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