Type and Basis of Complaint:
Type of Complaint:
Discrimination Harassment (including sexual misconduct) Retaliation
If you are filing a discrimination or harassment complaint, please indicate the protected status(es) that is/are the
basis of the alleged behavior:
Race/Ethnicity Nationality Sex/Gender Age
Marital Status Sexual Orientation Religion Veteran Status
Genetic Predisposition Disability
Respondent/Accused Information*:
Please identify the person against whom your complaint is made.
Name: _______________________________ Contact Information: ________________________________
Is this person a:
Student Faculty Visitor
Employee Vendor Other (Please specify)
Title/Department (if applicable): _______________________________________________________________
Relationship/Association to you: _______________________________________________________________
Name: _______________________________ Contact Information: ________________________________
Is this person a:
Student Faculty Visitor
Employee Vendor Other (Please specify)
Title/Department (if applicable): _______________________________________________________________
Relationship/Association to you: _______________________________________________________________
* If the person completing this form is the victim, you may choose to identify yourself or not. If you are a third
party complainant who is not the victim, include the victim’s identifiable information only if the victim wishes.
* Victims completing this form who provide personally identifiable information can expect the college to
follow-up with an appropriate investigation. For information-only reports, victims should omit all personally
identifiable information to ensure confidentiality.