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Discrimination and Harassment Reporting/Complaint Form

Equal Employment Opportunity/Affirmative Action Office
Human Resources
2801 W. Bancroft Street, MS 405
Toledo, OH 43606
(419) 530-1490 Fax

This report is NOT confidential.

Submitting this report notifies the Office of Equal Employment Opportunity.

ACKNOWLEDGEMENTS OF THE COMPLAINT
By submitting this complaint, the complainant understands that the complaint may be investigated and heard by other members of The University of Toledo Community for the purpose of determining its validity. Complainant further acknowledges that the responsibility of the EEO/AA Office is limited to conducting a fair and impartial investigation and hearing of the facts underlying this complaint and to report its findings and recommendations to the appropriate University authorities.

The University acknowledges and compiles with its duties under Title VI and VII of the Civil Rights Act of 1964, the Age Discrimination in Employment Act of 1967, the Age Discrimination Act of 1975, Section 503 and 504 of the Rehabilitation Act of 1973, and the American With Disabilities of 1990, as amended, as well as relevant state and local laws, by setting forth comprehensive frameworks for receiving, processing, investigating, and resolving complaints.

VERIFICATION
I hereby acknowledge that I have read the foregoing complaint. I am familiar with its contents and the statements therein are true to the best of my knowledge, information and belief. Filing this report DOES NOT constitute filing an official Police Report with either the University of Toledo Police Department or any local Police Department. To file an official Police Report, please contact the University of Toledo Police Department at (419) 530-2600 or in person at The Transportation Center on the main campus (for incidents occurring on the UT Campus Property) or contact the Law Enforcement Agency for the municipality in which the incident occurred (for incidents occurring off-campus).

The completed form may also be submitted in person, via fax, or mail to the address listed above.

Please fill out as much information as possible based on your knowledge of the situation.

A red asterisk indicates required information.

The following terms are used below -
Reporter: The person who submits the report. The reporter may be the complainant, a witness or knows about an incident or situation.
Complainant: The person who experienced the alleged violation or harm.
Respondent: The person accused of perpetrating the alleged violation or harm.
Witness: A person who saw or heard an incident occur or who has relevant information about it.

Reporters Information

In order that the EEO/AA Office may quickly handle your complaint, please supply the following information -

Your Full Name:

Your Position/Title:

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Student, Staff, Faculty, Other

Your Phone Number:

Your E-Mail Address:

Email address must be of a valid format.

Your Campus Address:

Cause of Discrimination(Required):

This field is required.

Urgency of the Report(Required):

This field is required.

Incident Date(Required):

This field is required.

Incident Time:

Incident Location(Required):

This field is required.

Specific Location:

Persons Involved

Please list all individuals involved, including the victim (complainant). Include as many of the listed fields as you can provide.

Name or Organization

Select Gender

Select Role

Rocket ID Number

Phone Number

Email Address

Questions

Please provide a description of the incident(s) in order of occurrence. Be certain to be as specific as possible, including full names, dates, times, and locations.(Required) This field is required.

What action and/or resolution are you hoping for?(Required) This field is required.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report