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
. 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
To view the DSA Harassment Policy go to:
Name ( you can type "withheld" and submit anonymously )
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:
gender identity or expression
other category I wish DSA to consider
retaliation for assisting or participating in a complaint or grievance
none of these categories
I don't know
The type(s) of conduct I experienced was ( check all that apply)
inappropriate or offensive remarks, slurs, or jokes (includes online)
physical or verbal intimidation
inappropriate physical contact or proximity
other verbal conduct ( includes online )
other physical conduct
retaliatory threats, intimidation, reprisals, and/or adverse actions related to organizing
How were you impacted/cause harm by the conduct ( check all that apply)
My submission to such conduct was made either explicitly or implicitly a term or condition of my affiliation with DSA (DSSL)
My submission or rejection of such conduct was used as the basis for organizational decisions affecting me
This conduct had the he purpose or effect of creating a hostile environment interfering with my capacity to organize within DSA
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.
A formal discussion between the accused and the Steering Committee to develop a plan to change the accused's harassing behavior(s) 1
The accused's suspension from committee meetings and other chapter or organizational events
The accused's removal from chapter committee(s
The accused's removal from DSA
Any and all other relief deemed necessary and just by the chapter or national leadership.
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