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Report Race-Based Incidents at RCDS
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Please keep my response anonymous.
Yes
No
Clear selection
Are you reporting a grievance about a racist incident that happened to you or someone else?
Myself
Someone else
Clear selection
If you are reporting for someone else, do you have their permission to report the incident?
Yes
No
Not applicable - I'm reporting for myself
Clear selection
Name of person reporting the incident. If you wish to report anonymously, please leave this blank.
Your answer
What is your class year? This will help us report data. If you wish to not include this information, please leave this blank.
Your answer
Contact information for the person reporting the incident (email and/or phone number). If you wish to report anonymously, please leave this blank.
Your answer
Date and time of incident
MM
/
DD
/
YYYY
Location: classroom or area where incident occurred
Your answer
What happened? Please describe the circumstance and description of the incident. If you are reporting on behalf of someone else, please include their name if you have permission from them.
Your answer
Name of offender(s), if known
Your answer
Use this space to provide any other information about the offender.
Your answer
Have you experienced or witnessed a similar incident before, with or without the same offender? If so, please describe here.
Your answer
Was there follow up to this incident? If yes, please describe.
Your answer
Is there any additional information you would like to share?
Your answer
Would you like to follow up/meet with someone from RCDS?
I want to meet with the Head of School
I want to meet with the Assistant Head of School
I want to meet with the Director of Diversity and Inclusion
I want to meet with the Director of Public Purpose
I want to meet with the Director of Health and Wellness
I want to meet with the division principal
I want to meet with a counselor
Other:
Clear selection
How do you identify racially and/or ethnically? This will help us report data. If you wish to not include this information, please leave this blank.
African American / Black
American Indian / Native American
Asian / Asian American / Pacific Islander
Caucasian / White
Latinx / Hispanic
Middle Eastern
Biracial / Multiracial / Other (Please specify)
Other:
Clear selection
With which gender do you most identify? This will help us report data. If you wish to not include this information, please leave this blank.
Male
Female
Trans
Non-binary / Genderqueer / Gender non-conforming
Other:
Clear selection
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