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Youth Safety Policy Form

JazzYYC Youth Safety Policy – Incident Details

This form is intended to provide individuals with clarity around the pertinent information and necessary details that would support a thorough investigation of a breach of JazzYYC’s Youth Safety Policy. Individuals wanting to make a complaint or provide details relating to an observed situation are welcome to use whatever format they are comfortable with (email, telephone, etc.).

This field is for validation purposes and should be left unchanged.

Complainant:

Respondent (Offender):

Name(Required)

Description of the Incident/Behaviour

Please describe in as much detail as possible about the incident(s) including:
(please provide details – who, when, what action was taken, etc.):

Incident/Behaviour Categories

Please respond to the following statements with a yes, no or unsure describing the incident or behaviour identified above. It involves:
A single incident of alleged harassment/bullying(Required)
Physical contact and/or assault(Required)
Verbal abuse and/or threats(Required)
Reprisal and/or retaliation(Required)
Abuse of authority(Required)
Sexual harassment (harassment which is gender-based/of a sexual nature)(Required)
Discriminatory harassment (based on prohibited ground of discrimination)(Required)
Are there any interim measures that JazzYYC could take to potentially alleviate the situation pending resolution of your complaint?
Have you initiated any other actions (formal or informal) to address the incident or behaviour? If yes, please provide details of the process, including the status.
Acknowledgement:(Required)
I certify the information provided in this complaint to be accurate, true and complete to the best of my knowledge. I understand that I will not be subject to any adverse treatment as a result of making this complaint, provided that it was made in good faith and has not been made for an improper purpose.

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