[DC GOVERNMENT] Grievance Referral Online Form

Grievance Referral Online Form

School Name

Reporting Party

First Name

Last Name

Your Phone Number

Your Email

Student Name

First Name

Last Name

Type of Incident

Discrimination

Harassment

Denial of Rights

Title IX/Sexual Harassment (unwelcome conduct that is of sexual nature or sex and/or gender based, including unwanted sexual touching and requests for sexual favors) Hot Spots (locations in schools where inappropriate activity occurs)

Unfair Treatment

Description of Incident (include date, time, name/title of person who committed act, and witnesses)

Are you willing to give your information or remain Anonymous

Yes, I am willing to provide my information

NO, Remain Anonymous I would like to file my complaint anonymously (Please note: DCPS will not be able to provide written responses on case outcomes with anonymous filings).

Griever Information

First Name

Last Name

Griever Street Address

Griever (City, State, Zip)

City

State

Zip

Supporting Documentation

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Supporting Documentation

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Affirmation of Truth

Yes, By checking this box, I hereby affirm that the statements contained in this form are true to the best of my knowledge.

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