This form is to document any safer spaces concerns that you have witnessed. Please fill it out if you wish a record be kept of it. You can enter as much or as little information as you wish. You may be anonymous or leave your name; whichever makes you more comfortable.

* 1. Date:

* 2. Nature of concern:

* 3. Did anyone speak up or otherwise address this concern?

* 4. How did it make you feel?

* 5. Do you wish for any follow up from this concern?

* 6. Are you interested in making an official complaint?

* 7. Do you wish to be contacted about this concern?

* 8. If yes, please leave your preferred mode of communication, whether that be e-mail, phone number, or something else:

Thank you for sharing your safer spaces concern with us. At any point, feel free to send e-mails to uvicpridesaferspace@gmail.com or to pride@uvic.ca, or to speak to any of the collective coordinators or the safer spaces coordinator in person. Their office hours are posted in the Centre as well as on the website.

T