Complaint Form Page 2

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Executive Order 1096
COMPLAINT FORM
Revised June 23, 2015
Attacment A
1. Identify the Respondent(s) against whom your complaint is made. For each respondent, provide the identifying information requested
below.
Relationship/Association with the campus:
Relationship/Association to you:
Respondent's name:
2. Describe the incident(s) or events(s), date(s), time(s), and location(s) giving rise to your complaint.
3. Describe the specific harm you have suffered resulting from the incident(s).
4. What did you or others do to try to resolve the issue? What was the outcome?
5. Identify individuals who may have observed or witnessed the incident(s) that you described.
Last Name
First Name
MI
Telephone
Position/Job Title
Cell Phone
E-mail
Last Name
First Name
MI
Telephone
Cell Phone
Position/Job Title
E-mail
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