Incident Report of an Allegation of Abuse or Misconduct October 11, 2018 erik shanabrough No Comments The Diocese of Bridgeport Incident Report of an allegation of abuse or misconduct This information will be communicated within 48 hours to the Office of Safe Environments. You may also call the Victim Assistance Coordinator directly at (203) 650-3265 or (203) 241-0987. Please do not report emergencies or imminent threat of harm. For these you should immediately dial 911. CT law requires that the Diocese of Bridgeport must report all allegations involving abuse of a minor or vulnerable adult to civil authorities which include local law enforcement in the town where the abuse is to have occurred and/or the CT Department of Children and Family Services (Care line 1-800-842-2288). Please be aware that anonymous reports are unable to be fully investigated by the Diocese or by the police. The CT Department of Children and Families and the Diocese of Bridgeport will handle your information with a high level of confidentiality.Name* First Last Phone*Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Date of Birth MM slash DD slash YYYY Age at time of abuseExact location(s) of the alleged incident(s)If more than one incident, please describe.Exact nature of alleged abuseThe frequency and duration of the alleged abuseSpecific date(s) alleged abuse occurredClick the + button to add additional dates. Names of all individuals you told about the alleged abuseClick the + button to add additional names. Name of the person who allegedly committed the abuse Last known address and any other contact information of the person who allegedly committed the abuseThe connection, if any, of the alleged abuser to the Catholic Church, including the person’s title and place of connectionPhysical description of the alleged abuserHave you sought treatment as a result of the alleged abuse? Yes No Please list all treatments receivedHave you reported this information to the CT Department of Children and Family Services? Yes No When did you report this to the CT Department of Children and Family Services and with whom did you speak?Have you reported this information to the police? Yes No When did you report this to the police and with whom did you speak?Please supply any other information that you feel is necessaryPlease upload any related documents or files that you feel are necessary10MB max size Drop files here or Select files Max. file size: 10 MB, Max. files: 10. Please let us know how we may assist youMay we call you? Yes No
