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.
Home Phone Cell Phone
Month Day Year
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.
Date of Receipt: _________________________
Received by: ________________________________________________________