Universityofnebraska Intakeform printable pdf download

Universityofnebraska Intakeform

UNIVERSITY OF NEBRASKA–LINCOLN

INTAKE FORM

Office of Institutional Equity and Compliance

128 Canfield Administration Building

Lincoln, Nebraska 685880437

(402) 4723417

(Please Print or Type)

Name

Student ___ Employee ___

Department/College

Supervisor’s Name & Title

Contact Phone (s) and times you may be contacted:

Can a message be left at this number? Yes ___ No ___

Complete Correspondence Address (City/State/Zip):

Give names of all parties involved in the incident leading to this report, their jobs and

departments (add sheets if necessary).

If you are reporting discrimination, what type are you reporting?

___ Race

___ Religion

___ National/Ethnic Origin

___ Color

___ Disability

___ Marital Status

___ Sex

___ Veteran’s Status

___ Sexual Harassment

___ Age

___ Sexual Orientation

___ Other (please explain):

Universityofnebraska Intakeform