Boulder Valley School District

AC-E2

  • A
  • Foundations and Basic Commitments

File: AC-E2 (pdf)
Adopted:   May 8, 2007
Revised:  October 23, 2012, February 8, 2022


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ONLINE FORM

 

                    NONDISCRIMINATION/EQUAL OPPORTUNITY
                             (COMPLAINT/GRIEVANCE FORM)

 

Date of Report: _______________

Do you wish to remain anonymous:  □  Yes    □ No

If not proceeding anonymously, name of Reporting Party (Complainant): __________________________________

Reporting Party Email: _______________________________________________

Reporting Party Information:

                  □ I am the person who experienced the misconduct.

                  □ I am reporting conduct I observed.

                  □ I am reporting conduct I learned about from another person.

I would like the report:

                  □ To be investigated.

                  □ To be used for informational purposes only

                  □ I am not sure

Date of the incident: _________________
 

Name(s) of school, department, and person(s) involved:

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________


Why do you believe this incident occurred:

          □ Age

          □ Ancestry/National origin

          □ Citizenship status/Immigration status

          □ Disability

          □ Sex/Gender

          □ Gender identity or expression

          □ Socioeconomic Status

          □ Race/Ethnicity

          □ Religion

          □ Sexual Orientation

          □ Other: ____________________

 

Description of the incident: 

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________
 

Did anyone witness the incident?  □ Yes  □ No
 

Name(s) of witness(es) to the incident: 

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

Have you reported the incident to other BVSD staff?  If so, please list name and response:

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________
 

If others are affected by the possible discrimination or harassment, please give their names:

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________
 

What would your ideal course of action to address the incident be?:

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________


Do you wish to be contacted?  □ Yes  □ No

Is there anything else you would like to share regarding this incident?

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

 

__________________________________________________________________
Signature of complainant                                                     Date

 

__________________________________________________________________
Signature of person receiving complaint                           Date

 

 

End of File: AC‐E2