Use this form to report allegations of the following actions against a Fernhurst YWCA resident: *

Check the appropriate box(es)

Sexual Assault

Sexual Abuse

Sexual Harassment

Your Name (optional):

First Name

Last Name

Resident (victim) Name: *

First Name

Last Name

Perpetrator Name, if known:

First Name

Last Name

If known, is the perpetrator also a resident at a TJMA facility/program?

Yes

No

Your relationship to the resident (victim): *

Relative

Spouse/Partner

Friend

Co-Worker

Employer

Other

Do you know if the resident has or plans to take legal actions in this matter? *

Yes

No

Describe the nature of the allegation as follows (select one): *

Staff Against Resident

Resident Against Staff

Resident Against Resident

How did you learn about the alleged action(s)? *

Saw it myself

Resident shared this information

Heard it from a third party

Witness

A TJMA employee

The perpetrator told me

Other

Upon submitting this form, this information will be reviewed by the agency PREA Coordinator. If you need to make an inquiry regarding your submission, you can reach them directly at: (844) 522-9222 *

I Understand