Community Response Scheduling Request Form

Thank you for taking time to share your proposed topic and program with the Community Response Team. As a DOSA community, we want to offer additional opportunities for us to come together to engage in (at times) difficult conversations, and (when possible) find support within our DOSA community when current issues arise that impact us and the communities we belong to.

By completing this Form, you are responsible for hosting and providing the logistics of your Community Response Gathering, based on the approval of the Community Response Team.

Requester's Information

Name *

Department

Email *

Phone

Information about the Concern and Impact

Please provide a brief description (300 words or less) about the concerning event that you would like to address with others in the division.

Brief description of program (200 words or less). Please note that the information below will be used to communicate the details about the upcoming Community Gathering with the division.

Has this event had an impact on students?

Yes

Has this event had an impact on staff in DOSA?

Yes

Information about the Proposed Logistics

Proposed Date

Year

Month

Day

Title/Subject of the Gathering

Time Needed

(maximum is 2 hours)

Estimated # of Participants

Presenters/Facilitators Name(s)

Room Set-up

(ex: circle of chairs; lecture, ect.)

Who Outside of the Division Would You Like to Invite?

Would critical campus partners be invited?

Yes

If yes, please list them here:

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

Math question * 1 + 6 =

Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.

Student Affairs

Division of Student Affairs

Community Response Scheduling Request Form