COMPLAINT FORM

 

  1. TODAY'S DATE: ____________________________


  2. COMPLAINANT: If more than one complainant, complete information for each. Add additional pages if necessary.

    3.  

    NAME OF COMPLAINANT:______________________________________________

    Address (Work): __________________________________________________________

    Address (Home): __________________________________________________________

    ______________________________________________________________
    (City)                                          (State)                                                        (Zip Code)

    Phone: _________________________________________ (Work)
                  (Area Code)           (Number)

     __________________________________________ (Home)
      (Area Code)           (Number)

    Status:   __Student __Faculty __Staff  __Administrator __External/Non-Campus

     

  3. TYPE OF COMPLAINT:     ___Discrimination         ___ Harassment         ___Retaliation

  4. BASIS OF THE COMPLAINT: (Check and provide the information requested for only those that the complaint is based on.)

__Race: Specify __________________________
__Sex:                ____Male            ____Female
__Color: Specify __________________________
__Creed: Specify __________________________
__Religion: Specify ________________________
__Age: Include date of birth __________________________________________
__National Origin: Specify ___________________________________________
__Disability: Specify name of disability _________________________________
__Marital Status: Specify ____________________________________________
__Sexual Orientation: Specify _________________________________________
__Reliance on Public Assistance: Specify type of assistance__________________
    ________________________________________________________________
__Membership/Activity in Local Commission: Specify name of local commission        ________________________________________________________________
__Retaliation: Specify reason for retaliation_______________________________
    ________________________________________________________________
  1. RESPONDENT(S)/ACCUSED: If more than one respondent/person accused, include complete information for each. Add additional pages if necessary.

    2.  

     

    NAME OF RESPONDENT #1:_______________________________________________

    Address (Work): ___________________________________________________________

    Address (Home): ___________________________________________________________

                        _______________________________________________________________
                                  (City)                                (State)                                              (Zip Code)

    Phone: ______________________________________________ (Work)
                  (Area Code)           (Number)

      ______________________________________________  (Home)
      (Area Code)           (Number)

    Status:    __Student   __Faculty   __Staff  __Administrator __External/Non-Campus

     

     

     

    NAME OF RESPONDENT #2:______________________________________________

    Address (Work): ___________________________________________________________

    Address (Home): ___________________________________________________________

                        _______________________________________________________________
                                  (City)                                (State)                                              (Zip Code)

    Phone: ______________________________________________ (Work)
                  (Area Code)           (Number)

      ______________________________________________ (Home)
      (Area Code)           (Number)

    Status:   __Student __Faculty __Staff  __Administrator  __External/Non-Campus

     

     

     

    NAME OF RESPONDENT #3:_____________________________________________

    Address (Work): __________________________________________________________

    Address (Home): __________________________________________________________

                        ______________________________________________________________
                                  (City)                                (State)                                              (Zip Code)

    Phone: ______________________________________________ (Work)
                  (Area Code)           (Number)

      ______________________________________________ (Home)
      (Area Code)           (Number)

    Status:   __Student __Faculty __Staff  __Administrator  __External/Non-Campus

     

  2. DETAILS OF COMPLAINT:

Explain your complaint in detail. Include the following information: Add additional pages if necessary.
    1. Describe the specific incident(s) of alleged discrimination, harassment, and/or retaliation. List times, dates, location, names and titles of the people involved in the incident(s).

      2. ___________________________________________________________________________
      ___________________________________________________________________________
      ___________________________________________________________________________
      ___________________________________________________________________________
      ___________________________________________________________________________
      ___________________________________________________________________________
      ___________________________________________________________________________
      ___________________________________________________________________________
      ___________________________________________________________________________
      ___________________________________________________________________________
      ___________________________________________________________________________
      ___________________________________________________________________________

    2. State the specific reason(s) why you believe you were discriminated/harassed/retaliated against because of your protected class status (e.g., race, sex, age, disability, etc.).

      3. ____________________________________________________________________________
      ____________________________________________________________________________
      ____________________________________________________________________________

    3. List those persons you believe were treated the same, more favorably, or less favorably than you, including their name, title, protected class status (e.g., race, sex, age, disability, etc.), and how they were treated differently.

Name
            Title 		      Protected
     Group Status		  
Different Treatment

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
  1. WITNESSES: List those witnesses you believe have information about your complaint. Include complete information for each witness listed. Add additional pages if necessary.

 

     

    NAME OF WITNESS #1:_____________________________________________________

    Address (Work):  ____________________________________________________________

    Address (Home):  ____________________________________________________________

                        ________________________________________________________________
                                  (City)                                (State)                                              (Zip Code)

    Phone: ______________________________________________ (Work)
                  (Area Code)           (Number)

      ______________________________________________ (Home)
      (Area Code)           (Number)

    What information can this witness provide?

    ______________________________________________________________________________________

    ______________________________________________________________________________________

    ______________________________________________________________________________________

    ______________________________________________________________________________________

     

     

     

    NAME OF WITNESS #2:_____________________________________________________

    Address (Work):   ____________________________________________________________

    Address (Home):   ____________________________________________________________

                        ________________________________________________________________
                                  (City)                                (State)                                              (Zip Code)

    Phone: ______________________________________________ (Work)
                  (Area Code)           (Number)

      ______________________________________________ (Home)
      (Area Code)           (Number)

    What information can this witness provide? 

    ______________________________________________________________________________________

    ______________________________________________________________________________________

    ______________________________________________________________________________________

    ______________________________________________________________________________________

     

     

    NAME OF WITNESS #3:_____________________________________________________

    Address (Work): _____________________________________________________________

    Address (Home): _____________________________________________________________

                        _________________________________________________________________
                                  (City)                                (State)                                              (Zip Code)

    Phone: ______________________________________________ (Work)
                  (Area Code)           (Number)

      ______________________________________________ (Home)
      (Area Code)           (Number)

    What information can this witness provide?  

    ______________________________________________________________________________________

    ______________________________________________________________________________________

    ______________________________________________________________________________________

    ______________________________________________________________________________________

     

  1. SUPPORTING MATERIALS/DOCUMENTS: List any written materials or other documents you believe may help in investigating your complaint. Provide the name, date, and explanation of the contents of the material/documents listed. Add additional pages if necessary.


    Name of Item #1: ________________________________________________________________

    Date of Item #1: _________________________________________________________________

    Explanation of Contents (Attach a copy if available)

    ______________________________________________________________________________

    ______________________________________________________________________________

    ______________________________________________________________________________



    Name of Item #2: _______________________________________________________________

    Date of Item #2: ________________________________________________________________

    Explanation of Contents (Attach a copy if available)

    ______________________________________________________________________________

    ______________________________________________________________________________

    ______________________________________________________________________________



    Name of Item #3: _______________________________________________________________

    Date of Item #3: ________________________________________________________________

    Explanation of Contents (Attach a copy if available)

    _____________________________________________________________________________

    _____________________________________________________________________________

    _____________________________________________________________________________

     

  2. PLEASE SIGN AND DATE YOUR COMPLAINT

    ____________________________________ __________________________
    Signature of Complainant Date