Fillable Discrimination Complaint Form (Central Connecticut State University)

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Discrimination Complaint Form (Central Connecticut State University)

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Central Connecticut State University
Discrimination/Harassment
Complaint Form
Equal Opportunity Employer/Educator (ODE, November 2017)
Name of Complainant: _______________________________________________ Date:
Address: _____________________________________________________________________________
City: ______________________________________ State: ____ Zip Code: ________________
Work Phone: __________________________ Home Phone: ___________________________
Cell Phone: __________________________ Email: ________________________________
Sex: Male Female Other__________________
Your status: Student Faculty/Staff External (Non-Campus)
Type of Complaint: Discrimination Harassment Retaliation
I was discri
minated/harassed/retal
iated against on the basis of my:
Age
Ancestry
Color
Criminal Record (State Employment)
Gender Identity or Expression
Genetics
Intellectual Disability
Learning Disability
Physical Disability
Mental Disorder
Marital Status
National Origin
Sex ( including pregnancy or sexual
harassment)
Sexual Orientation
Race
Re
ligious Creed
Retaliation
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C^h/: ________________________ EmailϮ: ________________________________
Veteran Status
CCSU’s Office of Diversity and Equity Complaint Form Page 2
Name of Respondent ϭ: ________________________________________________________________
Address: _____________________________________________________________________________
City: __________________________________ State: _________ Zip: _______________
Sex: Male Female Work Phone: _____________________________
Other: _____________ Home/Cell Phone: ____
__________________________
Status: Student Faculty
Staff
External (No
n-campus)
__________________
Specify
Name of ZĞƐƉŽŶĚĞŶƚ Ϯ: ____________________________________________________________________
Address: _____________________________________________________________________________
City: __________________________________ State: _________ Zip: _______________
Sex: Male Female Work Phone: _____________________________
Other: ____________ Home/Cell Phone: ______________________________
Status: Student Faculty Staff External (Non-campus)
__________________
Specify
Name of Witness ϭ: ___________________________________________________________________
Address: _____________________________________________________________________________
City: __________________________________ State: _________ Zip: _______________
Sex: Male Female Work Phone: _____________________________
Other: ______ Home/Cell Phone: ______________________________
Status: Student Facult
y Staff Externa
l (Non-campus)
__________________
Specify
I believe that I was discriminated/harassed/retaliated against by:
CCSU’s Office of Diversity and Equity Complaint Form Page 3
Name of tŝƚŶĞƐƐϮ͗ _______________________________________________________________
Address: _____________________________________________________________________________
City: __________________________________ State: _________ Zip: _______________
Sex: Male Female Work Phone: _____________________________
Other: ______ Home/Cell Phone: ______________________________
Status: Student Fac
ulty Staff  Exte
rnal (Non-campus)
Specify
Name of Witne
ss ϯ: ____________________________________________________________________
Add
ress:
________________________________
___________
__________________________________
City: __________________________________ State: _________ Zip: _______________
Sex: Male Female Work Phone:
_____________________________
Other: ____________ Home/Cell Phone:
______________________________
Status: Student Faculty Staff Externall (Non-ca
mpus)
__________________
Specify
Name of Witness ϰ: ___________________________________________________________________
Address: _____________________________________________________________________________
City: __________________________________ State: _________ Zip: _______________
Sex: Male Female Work Phone: _____________________________
Other: _____________ Home/Cell Phone: _____________________________
_
Status: Student Faculty Staff External (N
on-campus)
__________________
Specify
CCSU’s Office of Diversity and Equity Complaint Form Page 4
Explain your complaint in detail. Include the following information. Add additional pages if
necessary. Attach documents you believe may be helpful in investigating your complaint.
1. Describe the specific incident(s) of discrimination/harassment/retaliation. List dates, times,
locations, names, and titles of the people involved in the incident(s).
2. Explain why you believe that you were discriminated/harassed/retaliated against because of your
protected class status (race, age, sex, disability, etc.)
3. Provide the names and titles of people you believe were treated more favorably than you due to
your protected class status. List the protected class status (race, age, sex, disability, etc.) of each
person.
If more space is needed please attach to this form.
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
CCSU’s Office of Diversity and Equity Complaint Form Page 5
Please return form to:
Central Connecticut State University
Office of Di
versity and Equity
Davidson Hall, room 102
1615 Stanley St.
New Britain, CT 06050
If you have additional questions or to schedule an appointment, call 860-832-1652.
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Nov 2011.docx
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Discrimination Complaint Form (Central Connecticut State University)

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