Fillable Civil Rights Grievance Reporting Form (Arapahoe Community College)

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Civil Rights Grievance Reporting Form (Arapahoe Community College)

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Civil Rights Grievance Reporting Form
Page 1 of 3
Directions
If you believe that you have been subjected to unlawful discrimination and/or harassment on the basis of
sex/gender, race, color, age, creed, national or ethnic origin, physical or mental disability, veteran or military
status, pregnancy status, religion, genetic information, gender identity, and/or sexual orientation, we ask that
you fill out this complaint form. However, depending on the information you verbally provide, the College may
be obligated to investigate even without your formal, written complaint. The College can only base its findings
and take actions based on the information provided by you. If more space is necessary, please continue your
comments on a separate sheet of paper. The completed form must be returned to Angela Johnson, Director
of Human Resources at Angela.Johnson@arapahoe.edu or to ACCaskHR@arapahoe.edu.
Grievance Information
Name (Complainant): _____________________________________ S# (if applicable): _________________
Location: D
ate of Complaint:
_______________ ______________________________________________
Are y
ou an employee, student, authorized volunteer or guest/visitor? (Select one)
Employee Student Aut
horized Volunteer Guest / Visitor
If y
ou are not the victim, please include their name(s):
Is the victim an employee, student, authorized volunteer, or guest/visitor? (Select one)
Employee Student Authorized Volunteer Guest / Visitor
Name(s) of individual(s) you believe committed the alleged act(s) (Respondent):
Is the respondent an employee, student, authorized volunteer, guest/visitor, or the College? (Select one)
Employee Student Aut
horized Volunteer Guest / Visitor
Pleas
e describe the alleged incident(s), and when and where it occurred. Also, please attach any
supporting documentation and/or evidence you may have. If this concerns a class, please indicate the
course title.
Civil Rights Grievance Reporting Form
Page 2 of 3
Additional space for description of alleged incident(s):
Identify all individuals with knowledge of the conduct about which you are grieving.
We highly encourage attempting to resolve complaints informally. Would you be interested in attempting
this process? (Select one) Yes No
Please describe your requested remedy for this grievance.
Disclosure
To investigate your complaint, it will be necessary to interview you, the alleged respondent(s), and any
witnesses with knowledge of the allegations or defenses. The statements and the information that you
are providing may be attributed to you and could be included in any investigative reports that are
prepared.
Further, it may be necessary to include you as a witness in any hearing that may occur due to these
alleged incident(s).
Authorization to disclose identity of person reporting incident*: Yes No
*Please note limiting the College’s ability to disclose will affect the College’s ability to respond to the grievance.
Civil Rights Grievance Reporting Form
Page 3 of 3
Complainant Contact Information
Phone Number: _____________________________ Alternate Phone Number: _______________________
Email: ____________________________________________________________
Acknowledgment
I, ______________________________ am willing to cooperate fully in the investigation of my complaint
and provide whatever evidence the College deems relevant. I affirm that the information I am providing is true
and correct to the best of my knowledge. I understand that my statements and the information that I am
providing may be attributed to me and could be included in any investigation reports that are prepared. I also
understand that this investigation is confidential and for me to disclose any information that I have obtained
during the course of this investigation could interfere with the investigation. Further, I understand that
discussing this investigation with Non-College Officials could expose me to civil liability under current
defamation law. I also understand that if I do not fully cooperate, decisions will be made based on the best
information available to the College.
Signature: ________________________________________________________ Date: _________________
Family Educational Rights & Privacy Act (FERPA) Authorization (if applicable, for ACC Students)
I, understand that my complaint constitutes an “educational record” as
defined by the Family Educational Rights and Privacy Act of 1974 (FERPA). As such, I authorize the College
to di
sclose my name and/or the specific allegation(s) made by me to the Respondent of said allegation(s) and
to others identified as material witnesses during the course of this investigation. Other than the
aforementioned, I understand that I retain all other rights afforded to me under FERPA.
Signature: ________________________________________________________ Date: _________________
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Civil Rights Grievance Reporting Form (Arapahoe Community College)

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Completed 25 July 2020

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