Discrimination & Harassment Complaint Form (Page 2 of 2) in pdf

Discrimination & Harassment Complaint Form Page 2

SECTION III

Date of first alleged incident of discrimination or harassment:

Name of the person(s) committing action(s) against complainant, if known:

Name(s):

Their job or role (if known):

Description of incident(s):

Witnesses, if any, or others who should be contacted with knowledge vital to this investigation (include contact information for each person):

-Use additional paper if necessary-

Name(s):

Contact Information:

Others you may have discussed this incident with, including contact information for each:

Name(s):

Contact Information:

SECTION IV

If there are multiple instances of alleged discrimination or harassment, provide the dates, description of the incidents, and those involved:

 Section does not apply

Name(s):

Their job or role (if known):

Description of incident(s) with dates:

Has this matter of discrimination or harassment been previously reported?

 No

Reported to (Name, Title/Job):

 Yes

Date:

If yes, describe the outcome or resolution:

SECTION V

Remedy, outcome or resolution sought by complainant:

Once completed, please forward this form to the Civil Rights Compliance Officers at

CivilRightsCompliance@trocaire.edu

or drop off at Room 321B of the Choate Location

Discrimination & Harassment Complaint Form Page 2