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EOP Discrimination / Sexual Violence Policy Complaint Form

This form is used to report information necessary to initiate an investigation of alleged discrimination, harassment, sexual or gender-harassment, domestic or dating violence, stalking or retaliation pursuant to the Universities’ Equal Opportunity, Diversity and Affirmative Action Plan (“EO Plan”) and/or the Student Code of Conduct. All reasonable efforts will be made to maintain the involved parties’ confidentiality and privacy during the investigation and resolution procedure.

To file an incident report with Student Affairs / Student Conduct for non EO Plan related issues, please CLICK HERE.

To file a report with the Bias Incident Response Team, please CLICK HERE.

To file an incident report for alleged violation of the academic integrity policy, please CLICK HERE.

This report is routed to the Title IX Coordinator and/or Deputy Title IX Coordinator.

It is unlawful to retaliate against a student, employee or any other person affiliated with the University for filing a complaint or for cooperating in an investigation of a complaint.

All parties to a complaint may have a personal advisor (for union employees this may be a union representative) assist them throughout the process, in accordance with Sexual Violence Policy, Student Code of Conduct and applicable collective bargaining agreements.

Filing this incident report is only for resolution through the University's Complaint Investigation and Resolution Procedure. Completing this form DOES NOT constitute filing an official police report with either the Fitchburg State University Police Department or the City of Fitchburg Police Department. To file an official police report, please contact the Fitchburg State University Police Department at (978) 665-3111 or in person at 32 Clinton Street (for incidents occurring on Fitchburg State Campus Property) or the City of Fitchburg Police Department at (978) 345-9648 or in person at 20 Elm Street, Fitchburg, MA 01420 (for incidents occurring off campus in the city of Fitchburg).

If you are submitting a concern related to the *imminent safety* or *potential imminent safety of a student for any reason*, or you have submitted a report or emailed and it is an *emergency situation*, you need to call *Fitchburg State University Police at 978-665-3111*. Submitting a report is not sufficient to provide the needed assistance to any person, as it is not meant to provide immediate alert to the Dean of Students Office or other staff.

By submitting this form, I acknowledge that to the best of my knowledge and belief, the information listed herein is complete, true and accurate and not a "false charge" as defined under the EO Plan. I hereby submit this complaint under the University's Complaint Investigation and Resolution Procedures.

Background Information

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Your full name:

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Your physical address:

Nature of this report(Required):

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Urgency of this report(Required):

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Date of incident(Required):

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Time of incident:

Location of incident(Required):

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Specific location:

Involved Parties

Please list the individuals involved (excluding yourself), including as many of the listed fields as you can provide.

Name or Organization

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ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Hall/Address

Questions

Supporting Documentation

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