Personal Respect: Intake form

A Redeemer community member (Student, Faculty or Staff), may use this form to report concerns or incidents that have been experienced, witnessed or disclosed. You will receive a reply within two business days. At that time, you will be offered a confidential consultation and/or further information about resources, referrals and/or supports.

Name(Required)

First Last

Your relationship to Redeemer (check all that apply)(Required)

Student

Faculty

Staff

Personal Respect Advisor

Other

Your relationship to Redeemer – Other(Required)

Email(Required)

Preferred method of contact(Required)

Phone(Required)

Information about the incident(s) or concern(s)

I have(Required)

Have you tried any form of personal resolution?(Required)

Yes

No, I am not comfortable

No, but am willing

Please describe the resolution you have tried(Required)

The type of behaviour(s) or concern(s) that I am reporting is best described as(Required)

(check all that apply)

Racism and racial discrimination

Sexual and gender-based violence or harassment

Ableism and discrimination based on disability

Workplace harassment (employees) – not related to a human rights protected ground

Personal harassment (for students) – not related to a human rights protected ground

Not sure

Other

Please describe the types of behaviour(s) or concern(s)(Required)

Please provide the date of the incident. Where there have been a series of incidents, please provide the most recent date.(Required)

Please briefly describe the incident(s) or concern(s). For example, the name and role of any other involved person(s), date(s), location(s) of the incident(s), etc.(Required)

Please share any steps that you or others have taken to address the incident(s) or concern(s), including whether you have spoken to any academic or administrative employees, or a Personal Respect Advisor.(Required)

By submitting this form, I understand that the information contained in the form will be maintained as per the confidentiality and file retention practices of Redeemer’s Personal Respect Policy.(Required)

Yes