Title VI/Discrimination and Harassment Reporting Form

Title VI/Discrimination and Harassment Reporting Form
If you need to report an emergency or are reporting an incident that poses an imminent risk of harm, call Louisiana State Police at 225-777-8162, or dial 911. Please know that completing this form does not substitute filing a report with the police.

This form should be used to report concerns pertaining to possible violations of the Diesel Driving Academy Discrimination and Harassment policy and the Code of Student Conduct including discrimination or harassment based on or related to race, color, national origin, religion, age, disability, protected veteran status, genetic information, or other protected categories, classes or characteristics. Upon receipt of the report, the Title VI Coordinator will review the matter. Please note, Diesel Driving Academy cannot restrict any rights that would otherwise be protected from government action by the First Amendment of the U.S. Constitution.

Diesel Driving Academy respects the sensitivity of the information that may be included in this form and will make reasonable efforts to protect the privacy of those involved, in accordance with applicable state and federal law, while balancing the need to gather information to address the incident and take steps to eliminate prohibited conduct in order to protect Diesel Driving Academy’s community. Diesel Driving Academy prohibits retaliation of any kind against people reporting misconduct or any person's participation in the complaint or investigation process.

If you would like to speak with someone about completing this form, please call the Title VI Coordinator, Avery Vascoe, at 318-213-6616. Students may make a report anonymously, however, this may limit Diesel Driving Academy’s ability to investigate the incident or provide resources to the involved parties.
Background Information
The personally identifying information you provide below will be kept confidential
Your full name:
Your position/title:
Your phone number:
Your email address:
Type of Complaint:*
Urgency of this report:*
Date of incident:*

MonthDayYear
Date
Time of incident:
Location of incident: *
Specific location:
Involved Parties
Please identify the person(s) who are involved in the incident. Please list as many parties involved as you know and include as much information as you can as this information is tremendously helpful during investigation.
Name or Organization:
Select Sex:
Select Role
Location
Add another persons information if necessary:
About the Incident
In order for Diesel Driving Academy to effectively investigate the incident, we need to know as much about what happened as possible. The information you provide will be kept private and shared only with necessary and essential Civil Rights administrators. During the course of the investigation process, this information may be shared with the alleged perpetrator. However, this will not occur without first consulting with the victim as to their preferred approach to handling the situation.
Please provide a detailed description of the incident/concern using specific concise, objective language (who, what, when, where, why and how).*
Was law enforcement involved with the incident?*

NoYesUnknown
If law enforcement was invovled, please select the agency that responsed.

Shreveport Police DepartmentWest Monroe Police DepartmentBaton Rouge Police DepartmentOther law enforcement department
If "Other law enforcement department" was selected, please type in which law enforcement was involved.
Did anyone sustain an injury or experience a medical condition during the incident?*

NoYesUnknown
Was anyone transported to a hospital?*

NoYes, via ambulanceYes, via policeYes, via personal vehicleUnknown
Do you have any immediate concerns of safety or health? If yes, please explain.
If you were impacted by this reported incident, please describe how you would prefer the School to respond to the situation. (You will not be held to this response; it just gives us a starting point.)

No response neededReach out to discuss resources and options
If this is a possible Clery Hate Crime, please select relevant category/categories below.

TheftIntimidationSimple AssaultDestruction/Damage/Vandalism of PropertyHate Incident (any non-criminal incident)
Hate Crime Category of Prejudice, please select relevant category/categories below.

EthnicityRaceReligionSexual OrientationGenderGender IdentityNational OriginDisability
Supporting Documentation
Please add any additional documents that support your report. Attachments require time to upload, so please be patient after submitting this form.

Cancelof
Should be Empty:

Title VI/Discrimination and Harassment Reporting Form

Background Information

The personally identifying information you provide below will be kept confidential

Involved Parties

About the Incident

Supporting Documentation