Fillable CIVIL RIGHTS EQUITY GRIEVANCE FORM (Eastern Arizona College)

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CIVIL RIGHTS EQUITY GRIEVANCE FORM (Eastern Arizona College)

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CIVIL RIGHTS EQUITY GRIEVANCE FORM
You should review the Civil Rights Equity Policy on the Eastern Arizona College’s (EAC) website at
www.eac.edu/TitleIX/.
This form is designed to provide Title IX Officers with a method to gather uniform and specific information
related to an alleged incident(s) of discrimination, harassment (including sexual misconduct), or retaliation.
The College will use the information provided to begin an investigation, which may include contacting the
complainant, respondent, and/or any potential witnesses.
Complainant Information*:
Are you a:
Student Faculty Visitor
Employee Vendor Other (Please specify) ______________________
Is the complainant a:
Victim Witness Third-Party Complainant
If you wish to identify yourself, please fill in the information listed below:
Last Name: ________________________ First Name: ___________________________ MI:___________
Address: _________________________________________________________________________________
City: ____________________________ State: ________________________________ Zip: __________
Contact Number: ___________________ Email: _______________________________________________
* 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.
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.
Complaint:
While providing details is essential to investigating your complaint, please be advised that some or all of
the information you provide in this section may be shared with the person(s) you are accusing. You may
supplement this description later if you wish to share additional details.
1. Describe the incident(s)/event(s) including dates, times, locations, and any potential witnesses to the
behavior:
2.
Describe the impact that the behavior has had on you:
3.
NoHave you taken any action to stop
the behavior? Yes
If so, what actions have you taken and what was the outcome?
4.
Please add any additional documents or
information that supports your complaint.
Resolution:
What remedy are you seeking?
I certify that the information I have provided is true and accurate to the best of my knowledge.
________________________________________________ _______________________________________
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CIVIL RIGHTS EQUITY GRIEVANCE FORM (Eastern Arizona College)

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Completed 25 July 2020

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