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AC-E2

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  • Foundations and Basic Commitments
AC-E2

Nondiscrimination/Equal Opportunity (Complaint Form)

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

 

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