This is a report to submit to the UUA confidential record system for youth and adults whose actions at UUA youth ministry events warranted temporary or permanent suspension or restrictions in attending events. This report provides a summary of the status of the relationship between the individual and the program for future UUA staff should the individual wish to re-engage with UUA youth programming in the future. This does not replace the need to submit other necessary documentation including incident report forms. Contact Sarah Lammert, Co-Director of Ministries and Faith Development for information on submitting this form.

Name of individual:

Age at time of incident:

Staff people and roles writing report:

Date completed:
Current status of individual:

Individual contact information: (phone and email)

If youth, names and contact information of parents/guardians:

Current restrictions: (if can attend events, in what roles and with what restrictions)

Summary of precipitating events: (include dates, references to related incidents, and references to documentation)

Summary of actions taken so far:

Summary of responses and actions by the individual since the incident: (including restorative measures they’ve taken)

List of other documentation submitted not mentioned above:

Context and responsibility of system in events:

Unresolved concerns about the leadership or presence of this individual:

Follow up needed: (If follow up is already planned, please provide details and timeline. If follow up is contingent on the individual choosing to reach back out, provide your professional recommendations to the future UUA staff who may handle this process)