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Name of Coach and/or Support Agent working at the time of the incident:(Required) Email(Required)
Date of incident(Required)
MM slash DD slash YYYY
MOVE Class (i.e. 6:30pm EST; MOVE with DSAO)(Required) At approximate what time during or at which point in the MOVE class did it take place? For example: during warm up, during circuit number one.(Required) Type of incident:(Required)
Complaint made about service
Complaint made about staff
Complaint made about a MOVE Participant
Staff witness mistreatment
Disclosure (Select if MOVE Participant shares information with you that requires follow-up)
Name(s) of individuals who were involved in the incident:(Required)Description of the incident (what happened, who was involved, what led to the incident - provide as much details as possible in this section):(Required)Were parents/guardians/caretakers present?(Required) Staff action taken (de-escalation strategies, actions to address behaviour at the time of incident, did the Support Agent need to turn off camera, etc.):(Required)Was the participant's parent/guardian/caregiver notified?(Required) If parent/guardian/caregiver was not contacted, why not?(Required) Describe the conversation and reaction of the parent/guardian/caregiver:(Required)Did you contact your supervisor regarding the incident?
Describe any follow-up that was taken or additional information you'd like to share: