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: 

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