Thank you for your courage in submitting this form. Please know the responder receiving this will take it seriously and respond to you promptly. For that reason, we encourage you to identify yourself to ensure advocacy on your behalf.

We will maintain confidentiality except where required by law or in order to enable the diocese or law enforcement to complete a thorough investigation.

Please include as many details as possible for each violation (number additional violations):

Who- include the names of all involved including additional contractors or businesses

What- what are the details of the incident, including specific policies or laws that were broken

Where- where did the incident take place

When- times/dates of the incident

Why- if known, to the best of your ability, what do you assume are the suspect's motives

How- how was it possible to happen; were there usual policies that were bypassed or a lack of supervision

Thank you for bringing this incident into the light. You may be called upon to assist in the investigation, if required.

Reporter's Name

Your name; this section may remain anonymous if preferred, however it may be difficult to follow up on the incident.

First Name

Last Name

Your Church

Email

Phone

(###)

###

####

Name of the Accused

First Name

Last Name

Where does the accused go to church/ which Anglican church is involved?*

Is the accused a:*

Clergy person?

Lay person/not ordained?

The role/title of the accused:

Phone number of the accused (if known):

(###)

###

####

Email address of the accused (if known):

What is the nature of the relationship between the reporter (you) and the accused?

Describe the behavior you’re reporting, with as much detail as you’re comfortable sharing.

Reporting Form

ANGLICAN DIOCESE
OF THE MID-ATLANTIC

LINKS

Reporting Form

ANGLICAN DIOCESEOF THE MID-ATLANTIC

LINKS

ANGLICAN DIOCESE
OF THE MID-ATLANTIC