DSSL Confidential Harassment & Grievance Reporting Form
Thank you for speaking out. The Harassment and Grievance process is integral to protecting members, holding perpetrators accountable, and beginning healing and growth within the chapter. You are protected from any form of retaliation through resolution 33 of the national DSA charter.

This form will go directly to both of the current DSSL HGOs at DSSLHGO1@gmail.com. This report is only accessible by the two active HGO's- no other member of the chapter or chapter leadership will see it without your written consent.

If you feel that neither of the HGOs can be impartial or they are part of the harassment incident you may always directly contact nationalgrievanceofficer@dsausa.org

To view the DSA Harassment Policy go to:
Name ( you can type "withheld" and submit anonymously ) *
Preferred Pronouns *
Email Contact information ( you may need to scrub personal info or provide a new email to remain anonymous ) *
Phone Contact ( optional )
What Chapter are you a member of? *
Who is involved in this incident? ( list all names up to 5 ) *
List up to 5 witnesses ( optional )
Why do you believe this to be harassment ? It was on the basis of: *
The type(s) of conduct I experienced was ( check all that apply) *
How were you impacted/cause harm by the conduct ( check all that apply) *
Please describe the incident. 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 would you like your Harassment Grievance 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. *
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