Complaint Form For Discrimination/harassment/retaliation Complaints Page 3
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3Executive Order _______
Attachment No. 1
COMPLAINT FORM FOR
DISCRIMINATION/HARASSMENT/RETALIATION COMPLAINTS
6. Identify individuals who may have observed or witnessed the incident(s) that you described.
Last Name
First Name
MI
Telephone
Position/
Mobile Phone
Job Title
E-mail
Last Name
First Name
MI
Telephone
Position/
Mobile Phone
Job Title
E-mail
7. Do you have any documents that support your complaint?
(Please list and attach a copy.)
Yes
No
8. Describe the outcome(s) you expect from filing your complaint. Be as specific as possible.
Complainants may elect to have an Advisor present at meeting(s) and/or interview(s). 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 have selected an Advisor, please provide the name and telephone number of your Advisor.
Telephone
Last Name
First Name
MI
Mobile Phone
AUTHORIZATION
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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