DEIB Bias Incident Reporting Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Hello, thank you for coming to this website. This form is for reporting incidents of bias that families have experienced and/ or witnessed in and around the Mount Greylock Regional school district (including schools not part of but may feed into MGRSD). This form and any responses are managed by a small subcommittee within the DEIB-PCAN group.

The primary goal is for our collective (DEIB-PCAN) to provide support to the individual(s) and families impacted.

Additionally, these reports will be useful metrics in better understanding the frequency of bias incidents in the MGRSD, the response of the local schools, next steps in DEIB initiatives by the district schools, and next steps in DEIB initiatives by DEIB-PCAN.

Please note that the occurrence of this incident will be made available to members of the DEIB-PCAN Bias Incident group unless you indicate otherwise in the question below regarding anonymity.

Please fill out the form as completely as you feel comfortable.

Email *

Would you like to remain anonymous? *

Yes. (By checking yes, I understand that I may not receive any follow up but my report will be documented.)

Family/Last Name ( If anonymous, enter NA) *

Email and phone number *

Affiliated school/place of incidence *

Lanesborough Elementary

WES

Mount Greylock

Pine Cobble

WYC (Williamstown Youth Center)

Other

How did you become aware of this incident?

I witnessed the incident of bias.

My child shared it with me.

I heard about it from another parent/child.

Other:

Clear selection

When did the incident occur?

Please describe the BIAS incident with any details you would like to share (i.e. location, type of bias, other witnesses, evidence). *

Was anyone at the school notified? If yes, who and how? *

How can DEIB-PCAN help? Please check all that apply *

Please put the incident on the agenda for the next monthly meeting.

I need help advocating for/with my child/family at my school.

I would like a supportive listening ear and someone to help process the experience with.

Other:

Required

How may the small subcommittee reach you?

Phone

Text

In-person

No follow-up please

Each school should have a reporting method for an incident of bias on their website. Often they are linked in the school's online handbook as well. Would you like a member of this committee to help you find yours and/or fill this out with you?

Yes

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms