Discrimination Complaint

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.

Hall/Address:

Nature of the Discrimination(Required):

This field is required.

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Please describe the type of discrimination related to this complaint

Date of incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

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Involved Parties

Please include as much information as you can provide about the parties involved, if unknown, please leave blank

Name or Organization

Select Gender

What role did this person have in the incident?

ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Hall/Address

Questions

Please provide a detailed description of the incident or concern:(Required) This field is required.

Have you discussed this complaint with the respondent?(Required) This field is required.

If you answered "yes" to the previous question, please describe the results of that discussion. This field is required.

Please describe the remedy you are seeking (Not all remedies can be granted; however, if a violation of the University's policies have been found to have occurred, an alternative remedy may be implemented):(Required) This field is required.

Has the complaint been pursued through other internal administrative review procedures?(Required) This field is required.

If you answered "yes" to the previous question, please provide the date of the final administrative decision below the level of the President of the University: This field is required.

If the complaint was pursued through internal administrative review procedures, please provide the name of the University official who made the final administrative decision: This field is required.

If the complaint was pursued through internal administrative review procedures, please describe the administrative review procedures and results: This field is required.

Has this complaint been filed with another federal, state, or local agency or court?(Required) This field is required.

If you answered "yes" to the previous question, please provide the agency contact person's name, address, and phone number: This field is required.

How would you like this complaint to be pursued?(Required) This field is required.

I affirm that the above information is true to the best of my knowledge, information, and belief.(Required) This field is required.

Supporting Documentation

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Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Background Information

Involved Parties

Questions

Supporting Documentation

Submission