This form is to be used for filing a complaint alleging discrimination on the basis of age, ancestry, color, disability, national origin, race, religious creed, gender, sexual orientation, or veteran status.
Please respond to each of the following items.
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Name - ______________________________________________________________________________________________________
Street Address City State Zip Code - Telephone numbers:
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Home Phone Cell Phone - ____________________________________
Social Security Number - ____________________________________
Date of Birth - What is the specific incident(s) that has caused you to file a discrimination grievance? Please describe in detail relevant information including person involved, times, dates, places, witnesses, and, if applicable, any college activity(ies) involved.
- Date(s) when alleged incident(s) first occurred.
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Month Day Year - Did you attempt to resolve the complaint by contacting the individual(s) against whom the grievance is directed?
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Yes No - Describe what steps were taken to resolve the complaint, and the result of those steps. Include persons involved, times, dates, places, and witnesses.
I understand that submission of this form grants the Affirmative Action Officer my permission to conduct a full investigation of the above complaint. This investigation may involve review of confidential documents and interviews with relevant persons, including college employees and other witnesses.
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Signature
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Witness
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Date
Office Use Only:
Date of Receipt: _________________________
Received by: ________________________________________________________
