Discrimination & Harassment Complaint Form

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Trocaire College
Discrimination & Harassment Complaint Form
(please type or print clearly)
Date submitted:
SECTION I
Name of Complainant (print)
Signature of Complainant
Complainant’s Home Address
Complainant’s Phone Number(s)
Street Address
Home: (
)
City/Town, State
Cell:
(
)
Zip Code
Work: (
)
Complainant’s Role(s) at the College (check all that apply)
 Student
 Employee
Age:_____________________________
 Parent or guardian
Academic Program: _______________________________________
 Community member or other
SECTION II
The Discrimination or Harassment is Based on Your: (check all that apply)
 Race
 Age
 Color
 Marital Status
 Creed
 Military Status
 Religion
 Veteran Status
 Religious Practice
 Disability
 National Origin
 Domestic Violence Victim Status
 Ethnic Group
 Arrest or Conviction Record
 Sex (includes sexual harassment and sexual violence)
 Genetic Information
 Gender Identity
 Other (specify)___________________
 Sexual Orientation (the term “sexual orientation” means
heterosexuality, homosexuality, bisexuality, or asexuality)

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