Complaint Form Breadcrumb Home Division of Diversity and Engagement Equity and Inclusion Compliance and Equity Section Menu Division of Diversity and Engagement Skip Sidebar Diversity and Engagement Division of Diversity and Engagement Engagement Mocs in the City Sponsorships Community Collaborations MOC Forward Equity and Inclusion Resources Recruitment and Employment Search Committee FAQs Affinity Sources Training and Educational Opportunities Compliance and Equity Compliance and Equity Español ADA Accommodation Staff Viewpoint Diversity Additional Diversity & Inclusion Resources Center for Women and Gender Equity Disability Resource Center Office of Multicultural Affairs Supplier Diversity Program Veteran Student Services Name of Complainant: Address: Phone Number: Alternate Phone number: Email: Status of Complainant: Faculty Faculty Staff Staff Student Student Other Other If Complainant is an employee: Department: Position Title: Supervisor: If Complainant is a student: Student Status: Graduate Undergraduate Type of Complaint: Discrimination Discrimination Harassment Harassment Basis of Complaint: Age Age Color Color Disability Disability Gender Identity Gender Identity Marital Status Marital Status Military Service Military Service National Origin National Origin Parental Status Parental Status Pregnancy Pregnancy Race Race Religion Religion Retaliation Retaliation Sex/Gender Sex/Gender Sexual Assault Sexual Assault Sexual Harassment Sexual Harassment Sexual Orientation Sexual Orientation Sexual Violence Sexual Violence Veteran Status Veteran Status Name of Respondent(s): Department: Title: Status of Respondent(s): Faculty Faculty Staff Staff Student Student Other Other Relationship of Respondent(s) to Complainant: Co-Worker Co-Worker Client/Customer Client/Customer Faculty Faculty Subordinate Subordinate Supervisor Supervisor Student Student Other Other Describe specific act(s) alleged with date(s), time(s) and location(s), if possible, and the names and contact information of any witnesses who may have observed the incident or behavior and/or experienced similar treatment. Did you take any action to stop the alleged behavior? Yes No If yes, please summarize the action taken: How would you like to see the situation resolved and/or what remedy are you seeking? Additional information or comments: I am aware that an informal process is available to resolve the complaint, and feel that a formal complaint is appropriate to resolve the discrimination and harassment I allege in this complaint. I understand that I may have rights to relief under state and federal laws, and that complaints of discrimination may be filed with state and federal civil rights agencies. I certify that to the best of my knowledge, the information that I provided is accurate and the events and circumstances are as I have described them. I understand that a copy of this complaint will be provided to the respondent. I agree to cooperate with any investigation conducted by the University into this matter and provide whatever evidence the University deems relevant. While complete confidentiality cannot be guaranteed, I understand that all complaints will be handled in such a way that confidentiality will be protected to the fullest extent possible. I understand that if I am found to have knowingly misstated any material fact in this complaint I may be subject to discipline in accordance with applicable University policies and procedures for students and employees. Signature: Date: How did you find out about us? Leave this field blank
