Complaint Form

Background Information

Your full name:

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Your physical address:

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 each person's role in this incident.

Name or Organization

Select Gender

Select Role

ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Hall/Address

Questions

Please describe the alleged incident(s) and when and where it occurred.(Required) This field is required.

Identify all individuals with knowledge if the conduct about which you are complaining.(Required) This field is required.

We highly encourage attempting to resolve complaints informally. Would you be interested in attempting this process?(Required)

Yes No

This field is required.

Please describe your requested remedy for this grievance.(Required) This field is required.

To investigate your grievance, it will be necessary to interview you, the alleged Respondent, and any witnesses with knowledge of the allegations or defenses. The statements and the information you are providing may be attributed to you and could be included in any grievance reports that are prepared. Please note limiting the college's ability to disclose will affect the college's ability to respond to the grievance. Authorization to disclose identity of Complainant(Required)

Yes No

This field is required.

Select copy recipients

Yvette Atencio

Email me a copy of this report

Background Information

Involved Parties

Questions

Select copy recipients

Submission