JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
FCAC Grievance Form
This form was developed to ease the process of addressing conflict and other discrepancies in the workspace environment at FCAC. We acknowledge that instances of harmful conduct and discrimination are heavy to communicate and carry, and there are emotional and physical barriers one may have when discussing these situations with others. Please fill out the form to the best of your ability. If you feel more comfortable, you can contact FCAC council members Cathy Walling at cathy.a.walling@gmail.com or Jimena Cuenca at cuencaj9@gmail.com.
Sign in to Google
to save your progress.
Learn more
Name
Your answer
Email and Phone Number
Your answer
Date of submission
MM
/
DD
/
YYYY
Which definition would you attribute to the incident? (Definitions provided by "We Will Not Cancel Us" by Adrienne Maree Brown
Conflict - disagreement, difference, or argument between two or more people. Can be personal, political, structural.
Harm - suffering, loss, pain and impact; needs healing.
Abuse - behaviors (physical, emotional, economic, sexual, and more) intended to gain, exert, and maintain power over another person in a group.
Contradiction - the presence of ideas, beliefs, or aspects of a situation that are opposed to one another. Movements are often tense with the contradiction between what we believe and are fighting for and what we feel we must practice to navigate current conditions.
Critique - an analysis of assessment of someone's work or practices. This helps us grow collectively and are part of how we sharpen each other.
Other:
Date, time, and setting of the incident(s) leading to grievance.
Your answer
Please provide a detailed account of the incident(s), including person(s) involved or present and any background context that may be helpful.
Your answer
Please state the policies, guidelines, or values that have been violated.
Your answer
Does this account relate to another incident in which you have experienced harm with FCAC?
Your answer
How has this occurrence impacted your ability to perform your role with FCAC?
Your answer
What support do you need immediately? (Ex. space/re-grounding; one-on-one support conversation/peer-supervisor; mediation/conflict resolution, etc.)
Your answer
What support might you need long term? (Ex. new structures for you individually/internal staff/WG; tools needed; ideas that would feel like growth, etc.)
Your answer
Suggested action items:
Policy Revision/Change
Perform Mediator Role
Seek support from Native Movement
Suggested action items for Person(s) involved:
Harm Reduction Training
Private Conversation with Supervisor or FCAC Council Member
Mediated Conversation with person(s)harmed
Are there resources you would recommend for growth in this particular area?
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of fbxclimateaction.org.
Report Abuse
Forms
