Discrimination/harassment Complaint Form (Page 3 of 5) in pdf

Discrimination/harassment Complaint Form Page 3

Name of RESPONDENT #4:

(If more than one respondent, list complete information for each)

Address (local):

Address (residence):

City:

State:

Zip:



Sex:

Male

Female

Phone: [work] ____________________

[home] ____________________

Status:

 Student

 Faculty

 Staff

 Administrator

 External/Non-Campus

. A

XPLAIN YOUR COMPLAINT IN DETAIL

INCLUDE THE FOLLOWING INFORMATION

. A

ADDITIONAL PAGES IF NECESSARY

TTACH DOCUMENTS YOU BELIEVE MAY BE HELPFUL IN

INVESTIGATING YOUR COMPLAINT

1. Describe the specific incident(s) of discrimination/harassment/retaliation. List times,

dates, locations, names and titles of the people involved in the incident(s).

2. Explain why you believe that you were discriminated/harassed/retaliated against

because of your protected class status (race, age, gender, disability, etc).

3. Provide the names and titles of people you believe were treated more favorably than

you due to your protected class status. List the protected class status (race, age,

gender, disability, etc.) of each person.

Discrimination/harassment Complaint Form Page 3