Fillable DISCRIMINATION, HARRASSMENT, and COMPLAINT FORM (Northeast State Community College)

Fill Online, Printable, Fillable, Blank DISCRIMINATION, HARRASSMENT, and COMPLAINT FORM (Northeast State Community College) Form

Use Fill to complete blank online NORTHEAST STATE COMMUNITY COLLEGE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

DISCRIMINATION, HARRASSMENT, and COMPLAINT FORM (Northeast State Community College)

On average this form takes 13 minutes to complete

The DISCRIMINATION, HARRASSMENT, and COMPLAINT FORM (Northeast State Community College) form is 3 pages long and contains:

  • 0 signatures
  • 22 check-boxes
  • 40 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Northeast State Community College

BROWSE NORTHEAST STATE COMMUNITY COLLEGE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
DISCRIMINATION, HARRASSMENT, and COMPLAINT FORM
Northeast State is committed to developing and maintaining a climate in which racial harmony and cultural diversity are valued,
appreciated and accepted. Any current or former student, applicant for employment, or current or former employee who believes he
or she has been subjected to discrimination or harassment at Northeast State Community College (NeSCC) or who believes that he/she
has observed discrimination or harassment taking place shall present the complaint to the Assistant Director of Equity and
Compliance.
Every attempt will be made to encourage a complainant to provide a written complaint. The complaint shall include the circumstances
giving rise to the complaint, the dates of the alleged occurrences, and names of witnesses, if any. This form may be used to file a
complaint of discrimination or harassment but is not required.
Depending upon the nature and scope of a complaint, investigators may include, but are not limited to, the college’s Chief of Police,
Assistant Director of Equity and Compliance, Vice President of Academic Affairs, Vice President for Institutional Excellence and
Student Success, Director of Human Resources, or designees.
Date of the incident(s): ___________________ How were you directed to us? ______________________
I. Personal Information
Name ____________________________ Check your preferred contact method below:
E-Mail __________________________
Address___________________________ Work Phone _____________________
Home Phone _____________________
City ____________ State ____ Zip Code ______ Other (Cell) _____________________
II. Affiliation
Employee Department _____________________
Position Title _____________________
Supervisor _____________________
Student
Other _______________________________________
III. Respondent(s) person(s) and or department against who the complaint is being filed (attach list of additional names, if
needed)
Name ___________________________________
Address ___________________________________
City __________________ State _______________
Title (if applicable) __________________________
Department _______________________________
Title _____________________________________
IV. Basis of Your Complaint – check all that apply
Race Religion Sexual Harassment Marital Status Age
Color Gender Sexual Orientation Veteran Status Disability
National Origin Pregnancy Gender Identity
Other (List NeSCC Policy No.) ______________________________________________________________________________
V. Using the space below, describe the specific act(s) alleged with dates, locations(s), and the names and contact information
of any witnesses who may have observed the incident and/or experienced similar treatment. Your complaint is not limited
to the space provided. Feel free to attach additional materials that may assist in the investigation.
Date of the incident(s): ___________________
Name(s) of Witnesses (add additional names, as needed)
Name ___________________________________
Address ___________________________________
Phone_____________________________________
Email _____________________________________
Name(s) of Witnesses (add additional names, as needed)
Name ___________________________________
Address ___________________________________
Phone_____________________________________
Email _____________________________________
VI. How would you like to see the situation resolved and/or what remedy are you seeking?
Please describe the incident here.
Please describe the desired remedy.
VII. Acknowledgement
I certify that to the best of my knowledge the information that I provided is accurate and the events and circumstances are as I have
described them. I understand and acknowledge that a copy of this complaint will be provided to the alleged offender (respondent). I
am willing to cooperate fully in the investigation and provide whatever evidence the College deems relevant.
While complete confidentiality cannot be guaranteed, I understand that all complaints will be handled in such a way that
confidentiality will be protected to the extent possible. Information about the complaint will be shared on a limited basis only with
those who need to know. I further understand that filing a complaint does not keep me from filing an allegation with an external
agency nor extend time limits.
NeSCC does not tolerate adverse treatment of its employees or students because of the filing a complaint or providing information
related to a complaint. You should report any actions that may constitute retaliation to the Assistant Director of Equity and
Compliance immediately.
If you believe that you have been retaliated against, please check here:
Signature Date __________________________
Official Use Only.
Received by: ____________________________________________ Date: ______________________
Actions taken: ______________________________________________________________________
NeSCC-2-19-187
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

DISCRIMINATION, HARRASSMENT, and COMPLAINT FORM (Northeast State Community College)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 17 October 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document