Member Support & Sensitive Issues
Report Details
This form allows MCC to track incidents that are more sensitive in nature so that private details regarding member's experience is protected. Only the Vice President of Programs has direct access to all data submitted. Information shared in this form will be held in confidence and communicated with staff on a need to know basis.
Name of Staff Completing the Form
First Name
Last Name
Email
example@example.com
Program
Please Select
IPP
Youth Program
Conservation Corps
Piikuni Lands Crew
Member is a:
Please Select
Youth Program Leader
Youth Program Participant
Region
Please Select
CD
GY
NR
WW
Are you currently:
*
Documenting the incident for the first time
Updating initial submission
Submitting follow up documentation
What is the nature of the incident?
*
Behavioral health concern
Bias related incident
Conduct/discipline issue
Sexual misconduct
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Behavioral Health Concern
For this section, please only share the member's name in the name field and then refer to the member as "member."
Member Name
Please briefly describe what the member is experiencing and how you came to learn about it.
From your assessment, how would you categorize this incident at present?
Please Select
Level 4 (low)
Level 3 (moderate)
Level 2 (elevated risk present)
Level 1 (severe)
Please indicate all actions taken.
Discussed concern with the member
Facilitated co-leader/host debrief
Referred to MapWorks
Referred to medical professional
Called behavioral health consultant
Followed up with additional resources
Established Behavior Change Contract (BCC)
Put on light duty
Evacuated from the field
Self exited
Seeking/recommend early exit
Debriefed with staff
What are your next steps?
Please describe any questions you have or what would help you better address this concern.
Please upload any documentation delivered to the member for their personnel folder (Behavior Change Contract, suspension memo, early exit memos, etc.)
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Bias Related Incidents
We take instances of hate and bias seriously and appreciate your diligence in reporting this. You will hear from program leadership shortly.
Name of member(s) targeted by the hate or bias
Please briefly describe the incident(s) and how you came to learn about it.
Type of incident (select all that apply)
Repeated micro/macroaggressions not remediated through verbal warning
Derogatory language/slurs not remediated through verbal warning
Hate speech
Bullying
Intentional and ongoing exclusion
Harassment - Verbal
Harassment - Physical
Harassment - Written
Discrimination
Written slur/graffiti
Disruption to the community
Hate crime
Please indicate the identities, real or perceived, that were targeted in this incident(s) (select all that apply).
race
color
ethnicity
national origin
language
sex
size
gender identity
gender expression
sexuality/sexual orientation
disability
age
religion
veteran’s status or military service
marital or parental status
pregnancy
genetic information
reprisal
How is the impacted member(s) doing emotionally? What support have you provided them? What would they like to see happen?
What plan for follow up did you establish with the member impacted by hate/bias?
Is there anything that you need to feel equipped to support the impacted member or the crew as a whole?
Name of the alleged offender (if known)
Please indicate the alleged offender's role/relationship to MCC
Member/leader
MCC staff
Project partner
Member of the public
Other
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Bias Related Incident p.2
Name of the alleged offender
Please indicate all actions taken to address the incident (check all that apply)
Addressed behavior with the alleged offender(s)
Facilitated co-leader/host debrief
Issued verbal warning
Called behavioral health consultant
Established Behavior Change Contract (BCC)
Issued a Disciplinary Action Form (DAF)
Evacuated from the field
Self exited
Suspended for investigation
Seeking/recommend dismissal
Debriefed with staff
Is there anything you need to further address this incident?
Please upload any documentation delivered to the member for their personnel folder (BCC, DAF, suspension/dismissal memos, etc.)
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Conduct/Discipline Issue
Member(s) Name
Please briefly describe the conduct issues the member(s) are exhibiting and how you came to learn about it.
Please indicate all actions taken to address the incident (check all that apply)
Discussed behavior with the member(s)
Facilitated co-leader/host debrief
Issued verbal warning
Called behavioral health consultant
Established Behavior Change Contract (BCC)
Issued a Disciplinary Action Form (DAF)
Evacuated from the field
Self exited
Suspended for investigation
Seeking/recommend dismissal
Debriefed with staff
What are your next steps?
Please describe what would help you better address this issue and/or any questions you have at this time.
Please upload any documentation delivered to the member for their personnel folder (BCC, DAF, suspension/dismissal memos, etc.)
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Sexual Misconduct
We will respond to your report promptly; if you are submitting this outside of work hours and need more immediate attention, please call the Vice President of Programs.
Name of impacted student
Type(s) of incident(s) (e.g. sexual harassment, sexual assault, stalking, relationship violence, etc.)
When did the incident occur (if disclosed)
-
Month
-
Day
Year
Date
Please briefly describe the incident(s) and how you came to learn about it.
Did you explain to the member the difference between private and confidential resources and disclose your obligation to report the incident?
Yes
No
I am not sure
Does the member have concerns for their safety at this time?
Yes
No
I am not sure
What would the member like to see happen next?
What types of resources is the member interested in at this time?
What plan for follow up did you establish with the member?
Name of the alleged offender (if disclosed)
Please indicate the alleged offender's role/relationship to MCC
Member/leader
MCC staff
Project partner
Member of the public
Not disclosed
Other
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Sexual Misconduct p.2
Name of the alleged offender
To your knowledge, is the alleged offender aware of the allegations or member's concern?
Please Select
they are aware
they are not aware
I am not sure
What follow up, if any, has your team already had with the alleged offender?
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Incident Follow Up
Complete this form to provide further and/or final documentation regarding the incident.
Date of Follow Up Documentation
-
Month
-
Day
Year
Date
How is the member doing at this time?
Briefly describe how this situation was addressed/brought to resolution.
What, if any, remaining next steps are on your radar? (this could include a follow up plan 3-days or 3-weeks out where appropriate)
Please submit any remaining documentation for the member's personnel file (BCC, DAF, suspension/termination memo, etc.)
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Thank you for your crucial support to our members
We are so grateful for the care, compassion, and coaching you offer MCC members/participants. If a phone call/conversation would support you sooner rather than later, please be in touch.
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