Ugly Mugs Incident Report Form

Date of incident:

MM

DD

YYYY

Time of incident:

Hour

Minute

Second

AM PM

This report is:

Urgent

Not urgent

Unsure

Who did this happen to?

Me

Friend or co-worker

Unsure

Peer worker making a report on behalf of a peer

If you are making a report on behalf of someone else, do you have their consent?

Yes

No

I work as a:

At the time of the incident.

Cis-gendered woman

Transgender woman

Cis-gendered man

Transgender man

Gender fluid or non-binary person

None of these fit my work gender identity

Type of sex work:

At the time of the incident.

Brothel or parlour

Escort agency

Private incall

Private outcall

Street-based

Stripping

Online

Other

Ugly mug's gender identity:

Cis-gendered woman

Transgender woman

Cis-gendered man

Transgender man

Non-binary person

Unsure

Is this the first time the incident has been reported?

No, this is the first time I have reported it to Vixen

Yes, these are details to add to an existing report

Would you like this report to be shared within the sex worker community?

Yes

No

Unsure

I'd like to be contacted first

Would you like this incident to be reported to the police?

I already reported it to the police

I would like to report it to the police with a Vixen peer worker

I would like to report it to the police on my own

No, I do not want to report it to the police