CARE Team Referral Form

Tell Us About Yourself

A member of the CARE Team will evaluate the referral and determine what follow-up (if any) is necessary to address the concerns. We take care to preserve the identity of the referring party, however, we cannot promise anonymity. Please provide your name and contact information to allow us to call or e-mail if we have additional questions regarding your report.

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Your full name:

Your phone number:

Your email address:

Email address must be of a valid format.

Nature of this report(Required):

This field is required.

Urgency of Report(Required):

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Date of incident(Required):

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If you are not reporting a specific incident, please leave this blank.

Time of incident:

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If you are not reporting a specific incident, please leave this blank.

Location of incident(Required):

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Specific location:

Tell Us Who You Are Concerned About

Please list the individuals involved, including as many of the listed fields as you can provide. Fields may be left blank if information is not known at the time of the report. If you are concerned about yourself or would like to make a self-referral to our office, please submit your information below.

Name or Organization

Select Gender

Select Role

ID Number

Phone number

Email address

Tell Us About Your Concerns

Supporting Documentation

Please include any emails, screenshots, photographs, or other documentation you have that may be helpful to us in looking into this concern. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Tell Us About Yourself

Tell Us Who You Are Concerned About

Tell Us About Your Concerns

Supporting Documentation

Submission