Complaint Form (Page 3 of 3) in pdf

Complaint Form Page 3

Executive Order 1096

COMPLAINT FORM

Revised June 23, 2015

Attacment A

6. Do you have any documents or electronic communications (including text messages or email) that support your complaint?

(Please list and attach a copy.)

Yes

7. Do you have any physical evidence (such as photographs, videos, blood test or rape kits) that support your complaint? (Please describe.)

8. Describe the outcome(s) you expect from filing your complaint. Be as specific as possible.

You may elect to have an Advisor present at meetings(s) and/or interview(s) which may be a Sexual Assault Victim's Advocate. If you

indicate you will have an Advisor, you are authorizing that individual to accompany you to any meeting(s) and/or interview(s) regarding this

complaint. The role of the Advisor is limited to observing and consulting with you.

9. If you will be accompanied by an Advisor, please provide the name and telephone number.

Telephone

Last Name

First Name

Cell Phone

CERTIFICATION

I certify that the information given in this complaint is true and correct to the best of my knowledge or belief.

Print Name of complainant

Date

Signature of complainant

For University Use Only:

Date Complaint Received _______________

Signature__________________________________

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