Equity Incident Report

Equity Incident Report

This Reporting Tool is for Non-Emergency Incidents Only
Please complete this form anytime you experience or learn of discriminatory behaviors or actions related in any way to Family Service of Rhode Island - this tool is currently only for Family Service of Rhode Island employees. If you would like to submit an anonymous report, please note that our review panel will not be able to follow up with you for additional information or a resolution as the reporter.
Please select the type of report you would like to submit: *

I would like to submit a regular Equity Incident Report I would like to submit an anonymous Equity Incident Report

Background Information
Reporter's Name

First Name Last Name
Reporter's Email Address
example@example.com
Reporter's Phone Number
Please enter a valid phone number.
Date of incident: *

Month Day Year
Date
Who was the primary target of the incident? *
You selected other, can you specify?
Who engaged in the behavior? *
You selected other, can you specify?
Who is/could be affected?
What is the primary concern? *
Involved Parties
Incident Questions
Where did the incident take place?: *
Are you able to provide a specific address for where the incident occurred? *

Yes No
Incident Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Please provide a detailed description of the incident using specific concise, objective language. If you have a desired outcome, please include details here: *
Supporting Documentation
Photos, video, email, and other supporting documents may be attached below.

Files cannot exceed 25 MB
Cancel of
Should be Empty:

Background Information