COMPLAINTOFDISCRIMINATION,HARASSMENT,orRETALIATION
Thisformcanbeusedbystudents,employees,andthirdpartiestofileacomplaintof
discriminationorharassmentbasedongender,gendercharacteristicsandexpression,sexual
orientation,actualorperceivedgenderidentity,statusasavictimofasexualassault,
relationshipviolence,and/orstalking.Thisformcanalsobeusedbystudentsandemployeesto
fileacomplaintofretaliation.PLEASEPRINTORTYPEALLINFORMATION.
1. REPORTING/COMPLAININGINDIVIDUAL
(Indicateifyouarea□victimora□witness)
Name_______________________________________________________
Phone_______________________________________________________
Email________________________________________________________
CampusAddress_______________________________________________
Status:□Faculty□Staff□Student□Other:__________________
Date(s)ofallegeddiscrimination:Month__________Day_______Year________
Locationofallegeddiscrimination:___________________________
Isallegeddiscriminationiscontinuing?□Yes□No
2. Whoareyouallegingdidthis?
Name(s)___________________________________________________________
Status:□Faculty□Staff□Student□Other:__________________
Address:___________________________________________________________
Telephone:__________________________________________________________
E‐mail______________________________________________________________
