Fillable DICKINSON STATE UNIVERSITY Harassment Complaint Form (Dickinson State University)

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DICKINSON STATE UNIVERSITY Harassment Complaint Form (Dickinson State University)

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The DICKINSON STATE UNIVERSITY Harassment Complaint Form (Dickinson State University) form is 2 pages long and contains:

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  • 14 check-boxes
  • 22 other fields

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File type: PDF

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Page 1 of 2 AA/EOE
01/2019
DICKINSON STATE UNIVERSITY
Harassment Complaint Form
Last Name: ___________________________ First Name: _________________________________
Address: ________________________________________ City: ____________________ State: _____
Zip Code: __________ Email Address:________________________________________________
Home/Cell Phone Number: _______________________ Work Phone Number: _________________
Please check those that apply:
I am a: Student Faculty Staff
Other (Explain) ____________________________________________________
Complaint Focus:
Age Color Disability Gender
GINA National Origin Race Religion
Sexual Harassment Sexual Orientation
List the individual, department, or group that harassed you (if more than one, list all):
Name
Address
Phone
Explain the basis of your complaint on page two. Provide as much detail about the incident(s) as possible. Include date(s),
place(s), person(s) involved, witness(es), etc. Use additional sheets as needed.
Please submit to: Krissy Kilwein OR Keith James
May Hall 309 May Hall 210
Dickinson State University Dickinson State University
291 Campus Drive 291 Campus Drive
Dickinson, ND 58601 Dickinson, ND 58601
Office: (701) 483-2530 Office: (701) 483-2091
Krissy.Kilwein@dickinsonstate.edu Keith.W.James@dickinsonstate.edu
Procedures for Harassment Complaints are located at: www.dickinsonstate.edu/policymanual
Page 2 of 2 AA/EOE
01/2019
HARASSMENT COMPLAINT FORM DIRECTIONS
Explain the basis of your complaint. Provide as much detail about the incident(s) as possible. Provide as much detail about the
incident(s) as possible. Include date(s), place(s), person(s) involved, witness(es), etc. Use additional sheets as needed.
Signature: ___________________________________________________ Date: __________________
Print Name: _________________________________________________ EMPLID: ________________
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DICKINSON STATE UNIVERSITY Harassment Complaint Form (Dickinson State University)

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Completed 19 August 2020

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