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)