Boulder Valley School District
Adopted: May 8, 2007
Revised: October 23, 2012, February 8, 2022
Fill out the Complaint/Grievance 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