Discrimination Complaint Form
Name ________________________________________________________
Address ______________________________________________________
City/State _____________________________________________________
Telephone _____________________________________________________
Work Phone______________
Please provide the following information regarding the individual (s) or the department against whom you are filing the complaint:
Name____________________________________________________________________
_________________________________________________________________________
Department________________________________________________________________
Campus __________________________________________________________________
CAUSES OF DISCRIMINATION (Please check all that apply):
|
____Age ____Arrest/Conviction Record ____Color ____Creed ____Disability ____Marital Status |
____National Origin ____Race ____Harassment (including sexual harassment) ____Sex ____Sexual Orientation ____Other _____________________ *(please describe) |
IN REFERENCE TO:
|
(Employees)
____Discharge ____Hire ____Promotion ____Recruitment |
(Students)
____Grades ____Counseling ____Financial Aid ____Training and/or Apprenticeship ____Classroom Activity |
| Other (please describe) ___________________________________ |
1. Explain the details of the alleged discriminatory act.
2. When and how did the alleged act take place?
3. How were others treated differently?
4. Specify the action you are requesting to correct this situation.
5. Please list any witnesses.
(Attach additional pages or use the back if necessary.)
|
_______________________________
Complainant Signature |
__________________
Date |
|
______________________________
Department Official Signature |
__________________
Date |