Your International ACAC Membership *

Please indicate if you are a current International ACAC member.

Enter required value Yes, I am a current member I was previously a member I am not an International ACAC member

Disclosure of Your Information *

Let us know below if you want this report to be anonymous.

Your privacy is important to us. Each member of the review committee adheres to a confidentiality agreement which strictly guides how they may use or share your information. By providing your name and contact information, the committee will be able to contact you to request additional information if it is required, or provide updates to the situation you are reporting.

Your personal information, or the fact that you submitted a report, will not be shared publicly.

Your choice to disclose your information is optional, and we respect your decision. Please be aware that submitting this form anonymously limits the review committee's ability to follow up for more information or notify you of any resolutions. 

Enter required value I will provide my contact information I am submitting this report anonymously

Your Name *

Please provide your full (first and last) name below.

Your Email Address *

Please provide your email address below.

Your Phone Number *

Please include the country code.

Check this box if the phone number listed is available via WhatsApp.

Report Type *

Please select the type of report you are submitting.

Enter required value Code of Conduct Report Communications Report Event Concern Report Membership Eligibility Report Other

Report Type: Other

If you selected "other" in the previous question, please provide a brief summary about the reason for your report. There will be more opportunity to provide details in another section later. (40 character limit)

Involved Parties *

Please indicate the name(s) of the party/parties involved in this report. If you do not know their name(s), please provide any information you can to assist us in understanding who they are.

Involved Parties: Institution or Organization

Please provide the name of the institution/school, organization, or company where the party/parties work.

Involved Parties: International ACAC Membership *

To the best of your knowledge, are the involved party/parties member(s) of International ACAC? 

Please note that if this person(s) is not a member of International ACAC, we may be limited in our ability to follow up with them.

Enter required value Yes No Unknown

Location of Incident *

Please provide the location of the incident.

Enter required value International ACAC Annual Conference International ACAC Regional Institute International ACAC Social Media Page International ACAC Webinar or Online Meeting Other

Location: Other

Please provide information about the location if it was not an option in the previous question.

Date of Incident *

When did the incident occur? Please include the date(s), month(s), and year of the incident.

Description of Incident *

Please provide a detailed description of the incident or concern using specific, concise, objective language (who, what, where, when, why, and how).

Others Present *

If there were other people present, what were their names?

Supporting Documentation

Please provide any additional supporting documents here, which may include emails, text messages, social media messages, etc. 

Please note that only one file is able to be submitted in each field below. If you have further documentation you would like to provide, please end it to Executive Director Erin Garcia (EGarcia@InternationalACAC.org).

20MB max

Additional Supporting Documentation

20MB max

Additional Supporting Documentation

20MB max

Outstanding Questions/Needs

If there is any other information you would like to provide, questions you have for the committee, or needs you have regarding this report, please include them here.