Diversity Incident or Complaint Form Survey

RWA is committed to improving and expanding our diversity and inclusion efforts. The purpose of this form is to gather information to share with the Board of Directors, the Staff and the RWA Diversity Committee. By reporting the details of a specific incident or concern, leadership will have the opportunity to improve the association for all members.

Please note that you are welcome to complete and submit this form anonymously. Should you choose to submit the form anonymously, RWA will make no effort to determine your identity or to pursue discipline of offending parties. However, if you wish to be contacted regarding your concern, please feel free to include contact information.

In order to better understand the specific incident or concern you are reporting, we ask that you complete the following information:

Your role in the incident(Required.)

I was the target of the incident

I witnessed the incident

I heard about the incident

INCIDENT DETAILS

Please describe the approximate date and time of the incident(Required.)

Please describe the incident in as much detail as possible(Required.)

Location of the incident(Required.)

Did the offense occur during an RWA sponsored event (meeting, conference, etc.)?

Yes

Not sure

What action do you hope will occur as a result of your report?

RWA takes claims of mistreatment, bias or prejudice very seriously and we are committed to resolving issues to the best of our ability. Please note that submission of this form does not, in any way, supersede legal action or litigation on the part of the submitter.

First Name (Optional)

Last Name (Optional)

Preferred Contact Method (choose all that apply)

I prefer NOT to be contacted

I prefer to be contacted by e-mail

I prefer to be contacted by telephone

E-mail Address (Optional)

Preferred Phone Number (Optional)