Report a Case

Community Testimony Submission

This form supports a lawful community process for gathering testimonies about alleged harmful behavior within the Pisac community. Under Article 2, Clause 13 of the Peruvian Constitution, individuals may freely associate and form non-profit community councils or working groups dedicated to collective safety and wellbeing.

Introduction & Important Notes

Use this form to share your experience or observations regarding an individual whose actions may have caused harm or violated community ethics. Please provide as much detail as you feel comfortable sharing — specific information supports fairness and accuracy. You will find a section at the end of this form to share, in your own words, any additional details or clarifications you consider relevant.

Information will remain confidential unless you indicate below that you consent to your anonymous testimony being shared openly. Please note that this information may be shared with Council members or, if necessary, appropriate authorities. Ensure you are comfortable with this before proceeding.

If you are in immediate danger, please contact local emergency services (Comisaría de Pisac: 084-203-042). If you need emotional or psychological support, we recommend reaching out to a trusted friend, counselor, or local victim/survivor support organization before or while completing this form.

First Name

Last Name

Submit anonymously

If checked, your name will not be published in any public summaries. We may still contact you privately using the email you provided.

Are you a resident in this community?

Yes

Your relationship to this report

I am the person directly affected

I am a witness to the incident

Provide the person’s full name if known. If you do not know their full name, provide any identifying details (role, nickname, online handle, physical description). You may use a pseudonym if needed.

Your relationship to the person

Community member

Colleague/Co-worker

Volunteer / Staff

Friend

Family member

Client / Service recipient

Spouse / Romantic Partner

Other (Define Relationship)

Type(s) of harm experienced or observed

Physical harm

Sexual misconduct

Emotional / Psychological abuse

Unsafe Ceremony or Facilitation

Harassment

Discrimination

Financial exploitation

Neglect

Other

In the section below we’ll ask about specific details of your experience. Please take the time you need and share only what feels right to you.

Date of the experience (if known)

Location of the experience (e.g., event name, venue, or online space)

Describe the incident(s) in as much detail as you are comfortable providing. Include actions, words, and sequence of events if possible.

If there were witnesses, please share the names or descriptions of anyone who was present or affected (if you feel comfortable doing so).

Because this form does not currently accept file uploads, please email any supporting evidence to communitycouncilpisac@proton.me

Emotional or psychological impact

Please describe how this incident affected you emotionally or psychologically (e.g., stress, fear, anxiety, confusion, loss of safety).

Have you shared this experience with anyone else? (e.g., an organization, community group, or authorities)

Yes

If YES, who did you report to and what was the outcome? (Include dates, names of contacts, and any responses or actions taken, if known.)

Are you open to us reaching out to you?

Yes

Contact preference for follow-up (required) — we would only follow up to offer support, clarification, or care related to this report.

Yes — contact me by email

Yes — contact me by phone

No — I do not consent to public use

Phone number (only provide if you selected phone contact)

Permission to use your testimony in anonymized form — if you consent, your testimony may be used for reporting, advocacy, or educational purposes with all identifying details removed.

Yes — I consent to anonymized use for reporting, advocacy, or education

No — I do not consent to public use

Additional notes or context — this space is for sharing any other details of your experience that feel relevant, including information that may not fit into the questions above or that requires further explanation.

Has anyone, at any point, helped you in filling this form?

Yes

If YES, If yes, please select specifcy: friend, partner, family member, work colleague, etc.

Resources & confidentiality details

Thank you for taking the time to share your experience. Your testimony contributes to collective safety and helps guide appropriate community responses.

All submissions are handled with care and stored securely. We take reasonable measures to protect your privacy, but complete confidentiality cannot be guaranteed due to the potential need for community follow-up or external consultation.

If you are in distress or need immediate support, please reach out to:

Community Council – +51 916839576
Linea 100 (Peru) – National helpline for victims of violence: 100 (24/7)
Centro de Emergencia Mujer (CEM Urubamba) – 084-201-34

By submitting, you confirm that the information shared is truthful to the best of your knowledge and that you understand it may be used to support community safeguarding and ethical accountability processes.

Acknowledged