Incident Report

Please complete this form so the MDSG mediation committee can help resolve the situation in a way that is best for the group.

Contact information for the Mediation Committee:

• email: mediation@mdsg.org 
• phone: 718.930.2121 (telephone number for accessibility needs filling out the form)

Name

First

Last

You can report anonymously but we may not be able to fully process report without this.

Date of incident

Group that incident occurred in

* If occurred outside of group please describe

Zoom or in person?

• Zoom
• In Person

Person or people involved in incident

Description of incident

Was any action taken?

Submit

To download or print this form:

• Chrome and Firefox: File menu / Print / Destination: Save as PDF
• Edge: Select the three vertical dots on the top right side of browser / Print / Printer / Save as PDF
• Safari: File menu / Export as PDF