HEALING HANDS

Formal Grievance Form

This form is used to file a formal grievance. In order for your grievance request to be valid, you must have been personally affected. Please fill out all sections of this form and click submit when completed. If you need assistance in filling out this form, please contact the student coordinator or school director.

Your Name *

Your Phone Number

Your Email Address *

Your connection to Healing Hands *

Student

Staff

Faculty

Not Affiliated

Name of Respondent *

Phone Number of Respondent

Email of Respondent

If you believe you were treated adversely because of a protected characteristic (e.g. religion, age, etc.), check the box next to Discrimination. If you believe you were subjected to offensive conduct on the basis of a protected characteristic, check the box next to Harassment. If you believe you were treated adversely because you complained about discrimination, participated in someone else’s complaint, or you filed a complaint or charge of discrimination, check the Retaliation box. *

Discrimination

Harassment

Retaliation

Name of policy you feel was violated, if applicable

Please select relevant hate crime, if applicable

Intimidation

Simple Assault

Destruction of Property

Hate Incident (non-criminal)

Please select relevant category of prejudice, if applicable

Ethnicity

Race

Religion

Sexual Orientation