13-24 Annex C - Incident Report Harassment Complaint
Cadet Administrative and Training Orders (CATOs)
INCIDENT REPORT
Harassment Complaint
(reproduce locally)
CSTC/Detachment/Region Use Only
Case #
Police File #
INCIDENT TYPE
- Harassment
- Criminal infraction
- Other:
INCIDENT DATA
Date(s) incident(s) occurred:
Location of incident(s):
Date incident reported:
Reported to:
COMPLAINANT DATA (use additional sheet if more than one complainant)
NAME:
Status: Cadet / Staff Cadet (CSTC only) / CF / CI
Other:
Date of birth:
Gender: M / F
Home Unit:
Has respondent been notified? No / Yes – date:
Have parents been contacted? No / Yes – date:
By whom:
Was a written statement/complaint provided? No / Yes
Additional complainants? No / Yes – see attached sheet
RESPONDENT DATA (use additional sheet if more than one respondent)
NAME:
Status: Cadet / Staff Cadet (CSTC only) / CF / CI
Other:
Date of birth:
Gender: M / F
Home Unit:
Have parents been contacted? No / Yes – date:
By whom:
Was a written statement provided? No / Yes
Additional respondents? No / Yes – see attached sheet
INCIDENT DETAILS (provide as much detailed information as possible)
COMPLAINANT DATA
NAME:
Status: Cadet / Staff Cadet (CSTC only) / CF / CI
/ Other:
Date of birth:
Gender: M / F
Home Unit:
Respondent contacted? No / Yes – date:
Parents contacted? No / Yes – date:
By whom:
Was a written statement/complaint provided? No / Yes
RESPONDENT DATA
NAME:
Status: Cadet / Staff Cadet (CSTC only) / CF / CI
/ Other:
Date of birth:
Gender: M / F
Home Unit:
Parents contacted? No / Yes – date:
By whom:
Was a written statement provided? No / Yes
COMPLAINANT DATA
NAME:
Status: Cadet / Staff Cadet (CSTC only) / CF / CI
/ Other:
Date of birth:
Gender: M / F
Home Unit:
Respondent contacted? No / Yes – date:
Parents contacted? No / Yes – date:
By whom:
Was a written statement/complaint provided? No / Yes
RESPONDENT DATA
NAME:
Status: Cadet / Staff Cadet (CSTC only) / CF / CI
/ Other:
Date of birth:
Gender: M / F
Home Unit:
Parents contacted? No / Yes – date:
By whom:
Was a written statement provided? No / Yes
COMPLAINANT DATA
NAME:
Status: Cadet / Staff Cadet (CSTC only) / CF / CI
/ Other:
Date of birth:
Gender: M / F
Home Unit:
Respondent contacted? No / Yes – date:
Parents contacted? No / Yes – date:
By whom:
Was a written statement/complaint provided? No / Yes
RESPONDENT DATA
NAME:
Status: Cadet / Staff Cadet (CSTC only) / CF / CI
/ Other:
Date of birth:
Gender: M / F
Home Unit:
Parents contacted? No / Yes – date:
By whom:
Was a written statement provided? No / Yes
COMPLAINANT DATA
NAME:
Status: Cadet / Staff Cadet (CSTC only) / CF / CI
/ Other:
Date of birth:
Gender: M / F
Home Unit:
Respondent contacted? No / Yes – date:
Parents contacted? No / Yes – date:
By whom:
Was a written statement/complaint provided? No / Yes
RESPONDENT DATA
NAME:
Status: Cadet / Staff Cadet (CSTC only) / CF / CI
/ Other:
Date of birth:
Gender: M / F
Home Unit:
Parents contacted? No / Yes – date:
By whom:
Was a written statement provided? No / Yes
WITNESSES
None OR rank, name, unit, statement provided (no or yes) for each witnesses.
INCIDENT REPORTING (check those boxes that apply and provide name of person contacted and date contacted)
UCCMA
CO/OIC
DCCMA
RCCMA
Supervisor of Respondent (CSTC Only)
Supervisor of Complainant (CSTC Only)
Military Police
Civilian Police
Child Protection Agency
Other
INCIDENT RESOLUTION
Was ADR used? No / Yes (specifiy) Was incident resolved? No / Yes (specify)
Was any disciplinary action taken? No / Yes (specifiy)
SIGNATURE OF OFFICER COMPLETING THIS REPORT
Rank and Name:
Position:
Unit:
Home Telephone #:
Date:
Signature: