SAM Form

(for Sexual Abuse and Molestation Incidents)

Hi there, please answer the following questions and click submit to complete this form. If the answer to a question is unknown, please note unknown or leave blank. Please contact Human Resources at (208)424-2636 (office phone) or (208)598-1916 (cell phone) or via email at ttrader@alscott.com if you have any questions.

Name of Person Reporting the Incident

Email of Person Reporting the Incident

Phone Number of Person Reporting the Incident

Are you reporting the incident on your own behalf?

YesNo

Name of Victim involved in the incident.

Contact Information - Include the Victim's email address and/or phone number

Date of the Incident

Approximate Time of Incident

Hour

Minutes

Location of Incident

Event Outside of the Idaho Outdoor Fieldhouse FacilityPool AreaLocker Room AreaConference Room/Gathering AreaOffice AreaEntry Way AreaClimbing Wall AreaBathroom AreaHallwayIdaho Outdoor Fieldhouse HousingSummit Building (HBOT)Basketball CourtFitness Area (weights, turf, treadmill area)Other

Other Location

Type of Incident

Sexual Abuse (verbal or physical)	Inappropriate Contact (Physical)
Inappropriate Behavior (verbal)	Other

Other Incident Type

Name of the Accused

Age of the Accused

Did anyone witness the incident?

YesNo

Provide name(s) of witness(es) to the incident and contact information (phone number and email address).

Incident Description:

Describe how the incident occurred using only facts and observations. Please refrain from over-simplifying or over-complicating your description of the event. Leave a brief description here. You may provide additional supporting documents on the next question.

File Upload

Please upload any statements, photos, information or other supporting documents. Supports up to a total of 20 MB file(s) and the upload is slow so please be patient.

Any additional action taken?

No Additional Action Taken	Notified Police
Notified Child Protective Services	Emergency Services Contacted
Other

Other Action Taken

Contact Information