- A
- Foundations and Basic Commitments
File: AC-E2 (pdf)
Adopted: May 8, 2007
Revised: October 23, 2012
NONDISCRIMINATION/EQUAL OPPORTUNITY
(COMPLAINT FORM)
Date: _______________
Name of complainant: _________________________________________
School or Department:_________________________________________
Address: ___________________________________________________________________
Phone: ______________________ Email:______________________________________
Summary of alleged discrimination or harassment:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Name(s) of individual(s) allegedly engaging in prohibited conduct:
___________________________________________________________________________
___________________________________________________________________________
Date(s) alleged prohibited conduct occurred: _______________________________________
Name(s) of witness(es) to alleged prohibited conduct:
___________________________________________________________________________
___________________________________________________________________________
If others are affected by the possible discrimination or harassment, please give their names:
___________________________________________________________________________
___________________________________________________________________________
Your suggestions regarding resolving the complaint:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Please describe any corrective action you wish to see taken with regard to the alleged discrimination or harassment. You may also provide other information relevant to this complaint.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
_________________________________ ___________________
Signature of complainant Date
_________________________________ ___________________
Signature of person receiving complaint Date
End of File: AC-E2