INSTITUTE FOR APPLIED DIGNITY

BEHAVIORAL INCIDENT REPORT

Standard Form SS-404 (Rev. Jan. 2026)

Form No.

SS-404

OMB No. IAD-2026-007

Expiration: When You Learn

Authority: Self-Report Integrity Act of 2026 (Unofficial). Submission of this form constitutes acknowledgment that a dignity-related incident occurred and that you were a participant. Submission does not trigger any institutional investigation. Only personal reflection.
SECTION A Identifying Information
SECTION B Incident Assessment
SECTION C Red Flag Inventory
SECTION D Statement and Corrective Action

Your report is processed locally. No data leaves your device. Submission does not constitute a legal filing, a grievance, or a reason to contact them.