Report Misconduct Form — Diocese of the Mid-Atlantic

REPORTING CHILD OR YOUTH ABUSE

If you have witnessed or suspect the abuse of a child or young person, immediately report it to local authorities.

For assistance, see state-specific reporting laws.

After reporting the abuse to local authorities, please complete this form, so that we know about the incident and can provide trauma-informed care to all parties involved.

Thank you for your courage in submitting this form. Please know the responder receiving this will take it seriously and respond to you promptly. For that reason, we encourage you to identify yourself to ensure advocacy on your behalf.

We will maintain confidentiality except where required by law or in order to enable the diocese or law enforcement to complete a thorough investigation.

Reporter's Name

Your name; this section may remain anonymous if preferred, however it may be difficult to follow up on the incident.

First Name

Last Name

Your Church

Email

Phone

(###)

###

####

Name of the Accused

First Name

Last Name

Where does the accused go to church/ which Anglican church is involved?*

Is the accused a:*

Clergy person?

Lay person/not ordained?

The role/title of the accused:

Phone number of the accused (if known):

(###)

###

####

Email address of the accused (if known):

What is the nature of the relationship between the reporter (you) and the accused?

Describe the behavior you’re reporting, with as much detail as you’re comfortable sharing.

protection of Children

Diocese Reporting Form

REPORTING CHILD OR YOUTH ABUSE

ANGLICAN DIOCESE
OF THE MID-ATLANTIC

LINKS

protection of Children

Diocese Reporting Form

REPORTING CHILD OR YOUTH ABUSE

ANGLICAN DIOCESEOF THE MID-ATLANTIC

LINKS

ANGLICAN DIOCESE
OF THE MID-ATLANTIC