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FORMAL INCIDENT/COMPLAINT FORM
COMPLAINANT INFORMATION:
TYPE AND BASIS OF INCIDENT/COMPLAINT
(CHECK ALL BOXES THAT APPLY)
LAST NAME: _________________________________________ FIRST NAME: ___________________________________________________
EMPLOYEE/STUDENT ID #
D
EPT/DIV: ___________________________________________ TITLE: _________________________________________________________
PHONE #: ___________________________________________ E-MAIL: ________________________________________________________
IS COMPLAINT AGAINST A STUDENT STAFF MEMBER FACULTY MEMBER OTHER ______________________
FACULTY STAFF STUDENT OTHER ____________________________
THREATS INVOLVED PHYSICAL VIOLENCE INVOLVED ALCOHOL INVOLVED DRUGS INVOLVED WEAPONS INVOLVED
ASA SECURITY NOTIFIED POLICE CALLED (POLICE REPORT # ________________, REPORTED TO: _________________________________ (NAME, TITLE)
DATE OF INCIDENT: ______________ LOCATION OF INCIDENT (STREET ADDRESS OR BLDG NAME, ROOM #):
T
IME OF INCIDENT: ______________
A
GAINST WHOM ARE YOU FILING THIS COMPLAINT? (LIST THE NAME(S) OF THE INDIVIDUAL(S)/RESPONDENT(S). ADD ADDITIONAL PAGES IF NECESSARY)
RESPONDENT (PERSON ACCUSED) #1 RESPONDENT (PERSON ACCUSED) #2
FACULTY STAFF STUDENT OTHER FACULTY STAFF STUDENT OTHER
NAME & TITLE: _________________________________________________________ NAME & TITLE: ________________________________________________________
CAMPUS LOCATION _____________________________PHONE # ___________________ CAMPUS LOCATION _____________________________PHONE # __________________
INVOLVEMENT IN THE INCIDENT: INVOLVEMENT IN THE INCIDENT:
WITNESSES (LIST WITNESSES YOU BELIEVE HAVE INFORMATION ABOUT THE INCIDENT/COMPLAINT. INCLUDE COMPLETE INFORMATION FOR EACH WITNESS LISTED. ADD ADDITIONAL PAGES
IF NECESSARY. IF YOU WANT TO MAINTAIN CONFIDENTIALITY OF YOUR WITNESS, CREATE A SEPARATE ATTACHMENT TO THE INCIDENT/COMPLAINT FORM LISTING YOUR WITNESSES)
WITNESS #1 WITNESS #2
FACULTY STAFF STUDENT OTHER FACULTY STAFF STUDENT OTHER
NAME & TITLE: _________________________________________________________ NAME & TITLE: ________________________________________________________
CAMPUS LOCATION _____________________________PHONE # ___________________ CAMPUS LOCATION _____________________________PHONE # __________________
WHAT INFORMATION CAN THIS WITNESS PROVIDE: WHAT INFORMATION CAN THIS WITNESS PROVIDE:
DETAILS OF INCIDENT/COMPLAINT
(PLEASE PROVIDE THE FACTS OF THE INCIDENT IN AS MUCH DETAIL AS POSSIBLE.
DESCRIBE WHAT HAPPENED IN CHRONOLOGICAL ORDER, USING SPECIFIC, CONCISE, OBJECTIVE LANGUAGE (WHO, WHAT, WHEN, WHY AND HOW)
P
AGE 1 OF 2
BULLYING AGE DISCRIMINATION COURSE SCHEDULING
DATING/RELATIONSHIP VIOLENCE COLOR DISCRIMINATION CUSTOMER SERVICE
DOMESTIC VIOLENCE DISABILITY DISCRIMINATION HOSTILE ENVIRONMENT
PROPERTY DAMAGE GENDER DISCRIMINATION PHYSICAL ALTERCATION/FIGHTING ON PREMISES
STALKING NATIONAL ORIGIN DISCRIMINATION THEFT
SEXUAL HARASSMENT RACE DISCRIMINATION UNPROFESSIONAL CONDUCT
SEXUAL ASSAULT /FONDLING RELIGIOUS DISCRIMINATION VERBAL ALTERCATION
SEXUAL ASSAULT /RAPE SEXUAL ORIENTATION DISCRIMINATION OTHER ________________________
SEXUAL ASSAULT /STATUTORY RAPE VETERAN STATUS DISCRIMINATION
SEXUAL ASSAULT/OTHER _____________________ DISCRIMINATION/OTHER __________________________
DOWNTOWN BROOKLYN
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Brooklyn, NY 11201
Tel: 718 - 522-9073
NORTH MIAMI BEACH
3909 N.E. 163rd Street
North Miami Beach, FL 33160
Tel: 786-279-1740
HIALEAH
530 West 49th Street
Hialeah, FL 33012
Tel: 786-279-2643
MIDTOWN MANHATTAN
1293 Broadway/One Herald Center
New York, NY 10001
Tel: 212-672-6450
WWW.ASA.EDU
NAME: __________________________________________ DEPARTMENT/TITLE: ____________________________________
SIGNATURE: ______________________________________________ DATE: ________________________
DEPARTMENT HEAD NAME: ________________________________
SIGNATURE: ______________________________________________ DATE: ________________________
TO BE COMPLETED BY PERSON HANDLING THE COMPLAINT
(INPUT APPROPRIATE CODE INTO CAMPUS, IF IT INVOLVES A STUDENT)
DESCRIBE THE ACTIONS TAKEN AND THE FINAL OUTCOME, INCLUDING DATE OF RESOLUTION:
C
ODE:
PAGE 2 OF 2
SUPPORTING MATERIALS/DOCUMENTS (LIST ANY WRITTEN MATERIALS OR OTHER DOCUMENTS YOU BELIEVE MAY HELP IN INVESTIGATING YOUR COMPLAINT. PROVIDE NAME, DATE,
AND
EXPLANATION
OF THE CONTENTS OF THE MATERIAL/DOCUMENT LISTED. ADD ADDITIONAL PAGES IF NECESSARY)
DOCUMENT #1 DOCUMENT #2
NAME: ______________________________________ DATE:____________________ NAME: _____________________________________ DATE:____________________
EXPLANATION OF CONTENTS: EXPLANATION OF CONTENTS:
I AFFIRM, THAT TO THE BEST OF MY KNOWLEDGE, THE INFORMATION CONTAINED ON THIS FORM IS TRUE AND ACCURATE.
C
OMPLAINTANTS NAME: _______________________________________________ COMPLAINTANTS SIGNATURE: _____________________________________
DATE: _______________________
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