Fillable 900-1-2F2 - 900.1.2 [F2] _Adopted 06-08-10_

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900-1-2F2 - 900.1.2 [F2] _Adopted 06-08-10_

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900.1.2 [F2]
Adopted: 06/08/10
Page 1 of 2
ELIZABETH CITY STATE UNIVERSITY
Sexual Harassment Intake Form
To be completed by person who intakes a sexual harassment complaint
Name (Intake person): ___________________________________________________________
Status: Supervisor of Alleged Harasser Academic Dean EEO Officer
Dean of Students
Name of Alleged Harasser: _______________________________________________________
Status: SPA Employee EPA Employee Student Other Unknown
When did alleged incident occur: __________________________________________________
Where did alleged incident occur: _________________________________________________
List any witnesses: _____________________________________________________________
Witness(es) contact information: __________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
(Attach additional sheets, if needed)
Is there any documentation supporting the alleged complaint: Yes No
If yes, list (attached to Complaint Form): ____________________________________________
_____________________________________________________________________________
Details of alleged incident: _______________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
900.1.2 [F2]
Adopted: 06/08/10
Page 2 of 2
Details (Continued): ____________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
If additional space is needed, continue on reverse.
Options for Internal Resolution
The ECSU Sexual Harassment Policy (ECSU Policy 900.1.2), including options for resolution,
was discussed with Complainant.
The following option was selected by Complainant as a means of internal resolution
(Notwithstanding the complainant’s option, ECSU may conduct an administrative investigation
of any sexual harassment complaint):
Informal Process
Individual Resolution. Specific measures to be taken: _____________________
___________________________________________________________________
Fourteen (14) calendar day resolution outcome notice due to EEO: _____________
Mediation
Formal Process
Administrative Investigation and Resolution
Resolution Before a Hearing Body
By signing, I agree that the information contained herein accurately documents my account of
the alleged incident(s) and my option for internal resolution:
Complainant Signature: _________________________________ Date: ________________
Intake Person Signature: _________________________________ Date: ________________
Attach Complaint Form and forward this original Intake form to the EEO Officer.
Forward copies of the Complaint form and this Intake form to the Assistant to the Chancellor for
Legal Affairs.
____________________________________________________________________________
To be completed by EEO and Legal Affairs:
Date this form and Complaint form received by EEO: ________________
Date copies of Intake and Complaint forms received by Legal Affairs: ____________
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900-1-2F2 - 900.1.2 F2 _Adopted 06-08-10_

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Completed 5 December 2019

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