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If you believe that you have been subjected to discrimination, harassment (including sexual
harassment), or retaliation, you are encouraged to complete this form and submit it to one of
the College’s Civil Rights Compliance Officers below. The College prohibits retaliation
against any individual who makes a complaint. Please provide the information requested
below as accurately and completely as possible. Attach additional documentation if necessary.
Civil Rights Compliance Officers
Christina Vargas
Chief Diversity Officer/Title IX Coordinator
Ammerman Campus, NFL Bldg., Suite 230
533 College Road, Selden, New York 11784
(631) 451-4950
Dionne Walker-Belgrave
Affirmative Action Officer/Deputy Title IX
Ammerman Campus, NFL Bldg., Suite 230
533 College Road, Selden, New York 11784
1. Personal Information
Today’s Date:
Street Address: City, State: Zip:
Preferred Telephone Number:
Email Address:
Date of Birth:
Check one:
Student please provide your ID number: Faculty Staff (if faculty or staff, please complete section 2)
2. Job Information (SCCC employees only)
Your official job title:
Campus where you work (check one):
Eastern Ammerman Grant
Date of hire:
Department in which you work:
Immediate supervisor’s name and job title:
3. Name (and title) of the person(s) that allegedly discriminated, harassed, or retaliated against you (this person is
called the Respondent):
Respondent’s status (check one): Student Faculty Staff Other Don’t know
Respondent’s campus (check one): Eastern Ammerman Grant I don’t know
Relationship to you (check all that apply):
Professor Supervisor Co-worker Subordinate Other
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4. I believe I was discriminated against, harassed, or retaliated against because of my:
Gender/Sex Pregnancy National Origin/Ancestry
Race/Color Age Veteran/Military Status
Domestic Violence Victim status Gender Identity Sexual orientation
Sexual Harassment Sexual Violence/Assault Opposed discrimination
Retaliation Creed/Religious Belief - What is your religion?
Marital Status/Familial Status - What is your marital/familial status?
Disability Please share the type of disability:
If you do not have a disability, but you believe that the person acted because s/he perceives you as a person with a
disability, please explain:
Other (please specify):
*Note: if you do not believe the reason was discrimination, please inform the Civil Rights Compliance Officer.
5. What was done to you that you feel was unfair? (check all that apply):
Denied fair grade Denied access to program Denied accommodation
Denied equal pay Denied equal treatment Failed to hire
Denied training Denied Promotion Terminated you
Demoted Forced your retirement/resignation Denied access to activity
Subjected you to a hostile environment/harassment
Other (please specify):
6. Original (first) date of conduct complained of (on or about):
7. Most recent date of conduct:
8. Is the alleged conduct continuing? (check one): Yes No
9. Did you ask for an accommodation for a disability? Yes No If yes, to whom?
What was the accommodation sought?
10. If you were refused a job, promotion, transfer, etc., please tell us the following:
Title of job sought:
Did you apply? Yes No When did you submit your application?
To your knowledge, who got the job?
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11. Complaint Statement
Describe everything that happened to you that you feel was discriminatory, retaliation, or harassing. List each event and
action and be as specific as possible regarding who, what, when and where. List the date(s) names and titles of everyone
involved. Use as many additional pages as necessary. If you have relevant documents, please attach and submit them.
12. Did you complain or report this to anyone else? Yes No If so, to whom?
When did you complain?
What was the outcome?
13. Are there any documents that support your claim? Yes No If so, please attach and submit them.
14. Was anyone else treated the same way that you were? Yes No. If yes, please provide their contact information:
Job title or student
Telephone Number
15. Did anyone witness the treatment that you were subjected to?
Yes No. If yes, please provide their contact
Job title or student
What did they witness
16. For employees - Have you tried to solve your situation through the grievance process with your union, or filed a
complaint under any other College policy?
Yes No When did you file a grievance?
For students Have you filed a grade grievance or other complaint with Academic or Student Affairs?
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Yes No When did you file a grievance?
17. Have you filed a complaint with any other agency, court or department regarding this matter? Yes No
If so, where? On what date?
18. Have you made a report with College Public Safety? Yes No On what date?
19. Have you filed a criminal complaint with the Police? Yes No On what date?
20. What have you lost as a result of what happened to you? (salary, benefits, academic standing, etc.)
21. What remedy, outcome, or resolution are you looking for? Describe what it would take to resolve the issue(s)
I affirm that I have read the above allegation(s) and that the information I have provided above is correct and complete to
the best of my knowledge and belief. As per the College’s complaint procedures the investigator and the complainant shall
agree to keep all information gathered relative to the allegations of discrimination in confidence to the extent practicable or
allowable by law.
I have been advised that it is a violation of State and Federal statues to retaliate against an individual because they have
filed a discrimination complaint. If I am subjected to any adverse action that I feel may be retaliatory, I will promptly
report such to the Civil Right Compliance Officer(s).
I have been further advised that the filing of an internal complaint with the College is not a waiver of my right to file a
formal complaint of unlawful discrimination with the New York State Division of Human Rights (NYSDHR), The Equal
Employment Opportunity Commission (EEOC); the US Department of Education Office for Civil Rights (OCR), the
Federal courts or the State courts. Please see Appendix B for contact information.
In addition, I am advised that the filing of an internal complaint does not stop the statute of limitations for filing external
complaints with the EEOC, the New York State Division of Human Rights, litigation or any other agency hearing such
complaints. I am aware that should I choose to file a verified complaint with an outside agency, such a complaint must be
filed with the EEOC within 180 days of the alleged incident; with the New York State Division of Human Rights within
365 days of the alleged incident; and with the US Department of Education Office for Civil Rights (OCR) within 180 days
of the last act of discrimination (be advised that you may request a waiver of this timeframe from OCR.)
Date: Your signature:
For office use only: Received/Date stamp:
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SUNY Sexual Harassment Response and Prevention Policy Statement
Sexual harassment is a form of sex discrimination which is unlawful in the workplace under Title VII of
the Civil Rights Act of 1964, as amended, and the New York State Human Rights Law. Under Title IX of
the Educational Amendments of 1972, sexual harassment also is prohibited in the provision of educational
services and protects students and employees from sexual harassment.
Sexual harassment is prohibited and will not be tolerated at SUNY. The University has implemented
measures to address and prevent sexual harassment and is taking additional affirmative steps to increase
awareness of, and sensitivity to, all forms of sexual harassment in order to maintain a workplace and
learning environment free of its harmful effects.
Sexual harassment is a form of workplace discrimination and employee misconduct, as well as a form of
discrimination in the academic setting, and all employees and students are entitled to work and learn in a
campus environment that prevents sexual harassment. All employees and students have a legal right to a
workplace and a campus free from sexual harassment, and employees and students can enforce this right
by filing a complaint internally with the University, or with a government agency, or in court under federal
or state anti-discrimination laws, as detailed in the University’s Discrimination and Sexual Harassment
Complaint Procedure.
In accordance with applicable law, sexual harassment is generally described as unwelcome sexual advances,
requests for sexual favors or other verbal or physical conduct of a sexual nature when:
Submission to such conduct is made either explicitly or implicitly a term or condition of
employment or academic benefit; or
Submission to or rejection of the conduct is used as the basis for an employment or academic
decision affecting the person rejecting or submitting to the conduct; or
The conduct has the purpose or effect of unreasonably interfering with an affected person’s work
or academic performance, or creating an intimidating, hostile or offensive work or learning
Sexual harassment can include physical touching, verbal comments, non-verbal conduct such as leering or
inappropriate written or electronic communications, or a combination of these things. Examples of sexual
harassment may include, but are not limited to:
Seeking sexual favors or a sexual relationship in return for the promise of a favorable grade or
academic opportunity;
Conditioning an employment-related action (such as hiring, promotion, salary increase, or
performance appraisal) on a sexual favor or relationship; or
Intentional and undesired physical contact, sexually explicit language or writing, lewd pictures or
notes, and other forms of sexually offensive conduct by individuals in positions of authority, co-
workers or student peers, that unreasonably interferes with the ability of a person to perform their
employment or academic responsibilities.
Physical acts of a sexual nature, such as:
o Touching, pinching, patting, kissing, hugging, grabbing, brushing against, or poking
another person’s body.
o Rape, sexual battery, molestation or attempts to commit these assaults.
Unwanted sexual advances or propositions, such as:
o Requests for sexual favors accompanied by implied or overt threats concerning a target’s
job performance evaluation, a promotion or other job benefits or detriments, or an
educational benefit or detriment;
o Subtle or obvious pressure for unwelcome sexual activities.
Sexually oriented gestures, noises, remarks, jokes or comments about a person’s sexuality or sexual
experience, which create a hostile environment.
Sex stereotyping occurs when conduct or personality traits are considered inappropriate simply
because they may not conform to other people's ideas or perceptions about how individuals of a
particular sex should act or look.
Sexual or discriminatory displays or publications, such as:
o Displaying pictures, posters, calendars, graffiti, objects, promotional material, reading
materials or other materials that are sexually demeaning or pornographic. This includes
such sexual displays on computers or cell phones and sharing such displays while in the
workplace or classroom.
Hostile actions taken against an individual because of that individual’s sex, sexual orientation, self-
identified or perceived sex, gender expression, gender identity, and the status of being transgender,
such as:
o Interfering with, destroying or damaging a person’s workstation, tools or equipment, or
otherwise interfering with the individual’s ability to perform his or her employment or
academic duties;
o Sabotaging an individual’s work;
o Bullying, yelling, name-calling.
Such behavior can constitute sexual harassment regardless of the sex, gender, sexual orientation, self-
identified or perceived sex, gender expression, status of being transgender, or gender identity of any of the
persons involved. Sexual harassment is considered a form of employee and student misconduct which may
lead to disciplinary action. Further, supervisors and managers will be subject to discipline for failing to
report suspected sexual harassment or otherwise knowingly allowing sexual harassment to continue.
Employees and students who believe they have been subjected to sexual harassment may use the
University’s Discrimination and Sexual Harassment Complaint Procedure for more details on how to have
their allegations reviewed, including a link to a complaint form.
Retaliation against a person who files a complaint, serves as a witness, or assists or participates in any
manner in this procedure, is unlawful, is strictly prohibited and may result in disciplinary action. Retaliation
is an adverse action taken against an individual as a result of complaining about or provides information
regarding unlawful discrimination or harassment, exercising a legal right, and/or participating in a
complaint investigation as a third-party witness. Adverse action includes being discharged, disciplined,
discriminated against, or otherwise subject to adverse action because the individual reports an incident of
sexual harassment, provides information, or otherwise assists in any investigation of a sexual harassment
complaint. Participants who experience retaliation should contact the campus AAO, and may file a
complaint pursuant to these procedures.
SUNY campuses and System Administration shall take the necessary steps to ensure that this Sexual
Harassment Response and Prevention Policy Statement is distributed, implemented, and enforced in
accordance with their respective policies.
Policies and Documents:
Equal Opportunity and Anti-Discrimination Policy
Anti-Bullying Policy
Definition of Affirmative Consent
Options for Confidentially Disclosing Sexual Violence
Policy for Alcohol and/or Drug Use Amnesty in Sexual and Interpersonal Violence Cases
Sexual Violence Response Policy
Whistleblower Policy
Workplace Violence Prevention Policy
Annual Security Report
Anti-Discrimination Grievance Procedure for employees
Code of Professional Ethics
College Disciplinary Process vs. Criminal Justice Process
Faculty Resource Handbook
Sexual Harassment and Sexual Violence Complaint and Grievance Procedure for employees
Student’s Bill of Rights
Student Code of Conduct
Student Handbook
Non-Discrimination Notice
Notice under the Americans with Disabilities Act (ADA)
Age Discrimination Act of 1975, 42 U.S.C. § 6101 et seq.
Age Discrimination in Employment Act of 1967, 29 U.S.C. § 621 et seq.
Americans with Disabilities Act of 1990, 42 U.S.C. § 12101 et seq.
Title VI, Civil Rights Act of 1694, 42 U.S.C. § 2000d et seq. (nondiscrimination based on race,
color, and national origin in federally assisted programs)
Title VII, Civil Rights Act of 1964, 42 U.S.C. § 2000e et seq. (nondiscrimination based on race,
color, and national origin in employment)
Title IX, Education Amendments of 1972, 20 U.S.C. § 1681 et seq. (nondiscrimination based on
sex in education programs and activities)
Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. § 794 (nondiscrimination based on
Genetic Information Nondiscrimination Act of 2008, Pub. L. 110-233
NYS Executive Law Article 15 (New York State Human Rights Law)
NYS Education Law § 313 (nondiscrimination in educational programs)
NYS Education Law Article 129-A (regulation of conduct on college campuses and college
NYS Education Law Article 129-B (college implementation of sexual assault, dating violence,
domestic violence, and stalking prevention and response policies and procedures)
Pregnancy Discrimination Act of 1978 (amending the Americans with Disabilities Act)
Equal Pay Act of 1963, Pub. L. 88-38 (codified at 29 U.S.C. § 206(d))
Contacts for Making a Complaint:
Contact Public Safety at any time by calling (631) 451-4242 or 311 from any College phone.
In case of an emergency, call 911 to contact local law enforcement.
Civil Rights Compliance Officers (complaints against employees and third parties):
Christina Vargas
Chief Diversity Officer/Title IX Coordinator
Ammerman Campus, NFL Bldg., Suite 230
533 College Road, Selden, New York 11784
(631) 451-4950
Dionne Walker-Belgrave
Affirmative Action Officer/Deputy Title IX
Ammerman Campus, NFL Bldg., Suite 230
533 College Road, Selden, New York 11784
Associate Deans/Deputy Title IX Coordinators (complaints against students):
Eastern Campus and
Culinary Arts & Hospitality
Mary Reese
Campus Associate Dean of Student
Deputy Title IX Coordinator
Peconic Building, Room 228E
Riverhead, NY 11901
(631) 548-2515
Michael J. Grant Campus
Dr. Meryl S. Rogers
Campus Associate Dean of Student
Deputy Title IX Coordinator
Caumsett Hall room 106
Brentwood, NY 11717
(631) 851-6521
Ammerman Campus and
Sayville Center
Charles S. Bartolotta
Campus Associate Dean of
Student Services
Deputy Title IX Coordinator
Ammerman Building Room
Selden, NY 11784
(631) 451-4790
For students: Options for Confidentially Disclosing Sexual Violence
- these on-campus privileged
and confidential resources will not report crimes to law enforcement or College officials without your
permission, except for extreme circumstances, such as a health and/or safety emergency:
Mental Health Services
Ammerman Campus (631) 451-4069
Eastern Campus (631) 548-2650
Michael J. Grant Campus (631)-851-6351
Student Health Services
Ammerman Campus (631) 451-4047
Eastern Campus (631) 548-2510
Michael J. Grant Campus (631) 851-6709
State Police 24-hour hotline to report sexual assault on a New York college campus: 1-844-845-
For state-wide resources available at every SUNY campus including resources for SUNY
students travelling abroad or studying overseas, see SUNY’s
Sexual Assault & Violence
Response (SAVR) Resources.
External Resources:
Admissions & Education Programs and
New York State Division of Human Rights
Long Island (Suffolk) Office
New York State Office Building
250 Veterans Memorial Highway
Suite 2B49
Hauppauge, New York 11788
Tel: (631) 9526434
TDD: (718) 741-8300
Email: InfoLongIsland@hdr.ny.gov
Also see the Division of Human Rights website
U.S. Equal Employment Opportunity
New York District Office
33 Whitehall Street, 5th Floor
New York, New York 10004
Tel: (800) 6694000
Fax: (212) 3363790
TTY: (800) 669-6820
ASL Video Phone: (844) 234-5122
Also see the EEOC website
Office for Civil Rights New York
U.S. Department of Education
32 Old Slip, 26th Floor
New York, New York 10005
Tel: (646) 4283800
Fax: (646) 4283843
TDD: (877) 521-2172
Email: OCR.NewYork@ed.gov
Also see the Office for Civil Rights website.