Grievance/Discrimination/Harassment/Title IX Violation Form*
Complainant: Date Form Completed:
Address: City: State: Zip:
Home Phone: Business Phone:
1. If discrimination or harassment, charge based on:
Race/color Sex
Sexual orientation Religious creed
National origin/ancestry Disability or medical condition
Age Other
2. If grievance, charge based on alleged unfair treatment with respect to the application of:
Policy Procedure Regulation
3. Statement of grievance/discrimination/harassment/Title IX violation. Please provide the following
information (use an additional sheet if necessary).
a. Date(s), time(s), and location(s) of the alleged incident(s):
b. Description of each incident: e.g. Was any physical contact made? What was said and/or done?
c. Name(s) of person(s) against whom grievance is being filed (if known):
d. Name(s) of anyone else present during each incident:
e. Name(s) of others who might have been subjected to same or similar conduct:
f. Requested actions:
Complainant Signature: Date:
Complaint Recipient Signature: Date:
This form is to be used for non-academic grievances.
Revised: May, 2017
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