STATUS: Employee / Student / Visitor (list one below) Department (Employee/ Student / Visitor)
1. Type of request or incident alleged:
Campus Education (suggested training) Curriculum Other
Employment (application or accommodation) Facility
In-Class / On-line Instruction Website
2. Name(s) & number(s) of individuals involved and/or potential witness(es):
3. Describe the request or incident
4. Resolution or remedy suggested
Attach Separate Page if more space is necessary
Zip
Print/Signature of Complainant: Date:
STATEMENT OF COMPLAINT:
Mail form to: Office of Equal Opportunity: Administration Hall, Human Resources, 2nd Floor
Contact Information (phone / email)
Address
DATE OF ALLEGED INCIDENT / SUGGESTION
(if non-employee)
City/State
ASSESSMENT REQUEST / INCIDENT REPORT FORM
(Check all boxes that apply)
COMPLAINANT:
Name
Clear Form
Print Form
Please return to: Office of Equal Opportunity - Administration Hall, Human Resources, 2nd Floor
ASSESSMENT REQUEST / INCIDENT REPORT FORM
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