Reporting for Incidents of Racism within the APA (RIRA)

You are completing this form because you believe you were subjected to or personally witnessed an incident of racism or discrimination during an APA event or on APA property. While we do request that you provide the name of the person believed to have acted in a racist or discriminatory manner (“the subject of the complaint”), APA will not report that name. You may report anonymously, but if you give your name, APA will keep it confidential. The APA will report these events quarterly. Reports will not mention names or specifics that would identify the parties involved in its membership. However, to educate our members about racism and how to be anti-racist, APA will use the information to create educational materials on racism, discrimination, anti-racism, and professionalism.

Name: (optional)

1. What is your relationship to APA?

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2. Date of Incident: (mm/dd/yyyy)*

3. APA event where the alleged incident occurred:*

4. Name of the subject of the complaint:

5. What is the subject of the complaint’s role in APA?

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6. Who was the subject of the act you are reporting?

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6. Other:

7. Please describe the incident you are reporting in as much detail as possible. Be sure to include details such as exact language you recall being used, the specific acts or statements about which you are complaining, and any other details necessary to fully understand the facts you are reporting.*

8. If there were other witnesses to this event, please provide the names of the other people. (optional)

9. Did anyone who witnesses or experienced the event step in and say anything to the subject of the complaint about it or do anything to correct the behavior at the time. If yes, please describe what was done.

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