Fillable COMPLAINT OF DISCRIMINATION, HARASSMENT AND/OR RETALIATION GENERAL INFORMATION (Purdue University Northwest)

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COMPLAINT OF DISCRIMINATION, HARASSMENT AND/OR RETALIATION GENERAL INFORMATION (Purdue University Northwest)

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COMPLAINT OF DISCRIMINATION, HARASSMENT AND/OR RETALIATION
GENERAL INFORMATION
Complainant:
University Position/Status: Campus Phone:
Mailing Address: Home Phone:
E-mail Address:
Respondent:
Campus Phone: Mailing Address:
Relationship to Complainant: E-mail Address:
Position/Status of Respondent:
Respondent’s Supervisor’s Name:
TYPE OF COMPLAINT
Formal Informal
NATURE OF COMPLAINT
Harassment Discrimination Retaliation
ALLEGATION BASED ON
Race or Color
Sex
Ancestry
National Origin
Religion
Disability
Veteran Status
Age (40 or over)
Sexual Exploitation
Sexual Orientation
Sexual Harassment
Genetic Information
Gender Expression
Parental Status
Marital Status
Gender Identity
Stalking
Sexual Violence
Other, Explain:
Relationship Violence
COMPLAINT (Describe the nature of your complaint. Include a description, date(s) of the
incident(s), and name(s) of witness(es). Attach additional pages if necessary.)
Have you brought your complaint to the attention of any other University department or State or
Federal agency? Yes No
If yes, please state the name of the University department or agency and date:
CERTIFICATION
I certify that the information I have provided on this Complaint Information Form is true and
accurate to the best of my knowledge or belief.
Signature of Complainant Date
I
n accordance with the Procedures for Resolving Complaints of Discrimination and Harassment, a copy of this form
should be filed with the Purdue Northwest Office of Equity, Diversity, & Inclusion.
Last Revised July 1, 2014
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COMPLAINT OF DISCRIMINATION, HARASSMENT ANDOR RETALIATION GENERAL INFORMATION (Purdue University Northwest)

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Completed 16 August 2020

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