Sexual Harassment (Including Sexual Misconduct), and Retaliation On-Line Complaint Form

Background Information

If you wish to identify yourself, please fill in the information listed below.

If the person completing this form is the victim, you may choose to identify yourself or not. If you are a third party complainant who is not the victim, include the victim

Your full name:

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Your physical address:

Type of Complaint(Required):

This field is required.

Urgency of this report(Required):

This field is required.

Date of incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

This field is required.

Specific location:

Involved Parties

Please identify all parties involved in this incident.

Name or Organization

Gender

Role

ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Hall/Address

Questions

While providing details is essential to investigating your complaint, please be advised that some or all of the information you provide in this section may be shared with the person(s) you are accusing. You may supplement this description later if you wish to share additional details.

Describe the incident(s)/event(s) including date, times, locations, and any potential witnesses to the behavior.(Required) This field is required.

Describe the impact the behavior has had on you.(Required) This field is required.

Have you taken any action to stop the behavior?(Required)

Yes No

This field is required.

If you have taken action to stop the behavior, what actions have you taken and what was the outcome? This field is required.

Please add any additional information that supports your complaint. This field is required.

What remedy are you seeking?(Required) This field is required.

Supporting Documentation

Please add any additional documents that support your complaint. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Select copy recipients

titleix@centralaz.edu

Email me a copy of this report

Background Information

Involved Parties

Questions

Supporting Documentation

Select copy recipients

Submission