COMPLAINT REPORT FORM
At JACCD Design Institute Africa, we strive to create a safe environment for all members of our community. If you are concerned about the welfare of a student, you can use this form to report your concerns. The form can be used by staff, students, friends or family.   

JACCD DIA is committed to safeguarding and promoting the welfare of all members of the community. Reporting incidents and filling this form will help us achieve this goal. 
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CONFIDENTIALITY
Kindly note that the information you provide will be treated with the utmost confidentiality in accordance with data protection legislation. However, we may need to take specific actions based on the submitted information to protect the health and welfare of the JACCD DIA  community.
1. COMPLAINANT'S DETAILS
You may choose to report confidentially or anonymously. If you choose to report confidentially, kindly provide your details and all details of the event. If you choose anonymous reporting, you may skip the non-required options. 
Please note that anonymous complaints will be harder to treat. We highly encourage you provide names and full details. We will ensure to protect the person reporting the incident.
a. How will you like to report? *
b.  Please provide your name here
c. What is your gender 
 *
  d. How are old you  ?  
 *
2. INCIDENT REPORT
In this section, kindly provide us details of the incident you would like to report.
a. What is the nature of the complaint? *
Required
b. Please provide a brief, factual explanation of your concern or observation.
 *
c. Location of the incident *
d. Date incident(s) occurred (if applicable)
MM
/
DD
/
YYYY
e. Time incident(s) occurred (if applicable)
Time
:
f. Witness(es) (if applicable)
g.Is this the first time this incident has occurred? *
h. Have you spoken to a third party/ Is anyone outside of the school aware of the incident? 
 *
i. If yes, please provide us with more details
j. Have you reported this incident before to a staff member? (lecturers, head of departments, student affairs, safeguarding officer, etc) *
k. Who did you report to and what happened after?
l. Do you think the incident happened because the affected person is part of a marginalized group (disability, sexual orientation, socio-economic background, etc) *
m. If yes, please provide more details
3. PERSONS INVOLVED 
Please provide as much information as possible identifying the student(s) of concern and or the staff member(s) involved 
a. Are you reporting an incidence  about yourself ? 
 *
b. If you are reporting an incident about someone, please provide the name and contact of the person(s)
c. Name(s) of staff member(s) involved and their position/ role in the school
4. FOLLOW UP/ CASE MANAGEMENT
  a. Do you or the affected person need immediate help?  
 *
b. What kind of help do you need?
c. How would you like to proceed? *
d.  How can we contact you?
e. Do you give consent to share the information you have provided with people who can help us manage the case? ( Where it may not be safe, or when other people are at risk, or if a crime was committed.)
 *
f. Do you give consent for us to share your name with the student concerned?
 *
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