DSA Fort Collins Harassment Grievance Form

According to Resolution 33 adopted by DSA,

Members shall not engage in harassment on the basis of sex, gender, gender identity or expression, sexual orientation, physical appearance, disability, race, color, religion, national origin, class, age, or profession. Harassing or abusive behavior, such as unwelcome attention, inappropriate or offensive remarks, slurs, or jokes, physical or verbal intimidation, stalking, inappropriate physical contact or proximity, and other verbal and physical conduct constitute harassment when:

Submission to such conduct is made either explicitly or implicitly a term or condition of a member’s continued affiliation with DSA;

  • Submission or rejection of such conduct by an individual is used as the basis for organizational decisions affecting such individual; or

  • Such conduct has the purpose or effect of creating a hostile environment interfering with an individual’s capacity to organize within DSA.

Resolution 33 also prohibits retaliation against a person who assists someone with a complaint of harassment or participates in any manner in an investigation or resolution of a complaint of discrimination or harassment. Retaliatory behaviors include threats, intimidation, reprisals, and/or adverse actions related to organizing.


Sign in to Google to save your progress. Learn more
Name (if you leave this blank, your grievance can be submitted anonymously)
Email where you can be reached (please delete identifying information from your email if you wish to remain anonymous) *
Phone number (optional)
City (optional)
State (optional)
DSA Chapter *
Person(s) (up to five names separated by commas) or DSA body (Steering Committee, Caucus, etc) against whom you are filing a grievance, or put "anonymous/unknown." *
Witnesses (up to five names, separated by commas, of people with direct knowledge of the facts relating to your grievance)
My Harassment Grievance (a short summary of what happened) *
Why I believe this to be harassment (check all that apply): *
Required
The type(s) of conduct I experienced was (check all that apply): *
Required
How I was impacted/caused harm by the conduct (check all that apply) *
Required
Description of the Basis for My Harassment Grievance:
Tell us about what happened. Please be as specific as possible, including the Who, What, Where, Why, and How of what happened, referencing the categories you selected above. Remember that DSA is committed to creating a space that is welcoming and inclusive to members of all genders, races, and classes: why did that not happen in the situation you have described? Please try to be concise -- if you have additional documents to submit, you will be asked when speaking with the chapter harassment grievance officers (HGOs) to submit them at that time. *
How I Would Like My Harassment Grievance to be Resolved (check all that apply): These are the remedies authorized by Resolution 33. While some or all of these remedies may not be appropriate in your situation, depending on the outcome of the investigation, this will assist the HGOs/National Grievance Officer in developing a satisfactory remedy for the fear of harassment, abuse, or harm.   *
Required
If you wish a response, please provide an email address or phone number where you can be contacted. This form goes to dsafortcollinshgo@gmail.com, and will be kept confidential unless you authorize contact with the individuals or witnesses you name. 

The HGOs will contact you within seven business days to obtain any additional information and/or discuss with you the grievance process, so that you may determine whether you choose to move forward with the processing of a formal grievance.

DSA Fort Collins Chapter Harassment Grievance Officers (HGOs)

Addison N.

Micah D.

August-Carter N.

Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms