Harassment, Discrimination (Including Sexual Misconduct) and
You should review the College’s Non-Discrimination & Harassment Policy and Grievance Procedure on the CBC
website at: http://www.columbiabasin.edu/index.aspx?page=207.
This form is designed to provide Columbia Basin College students, employees, faculty, vendors, visitors, or others
with a method to report specific information related to an alleged incident(s) of discrimination, harassment
(including sexual misconduct), or retaliation.
You are not required to complete the entire form in order for the complaint to be submitted. The College will use
the information provided to begin evaluating the complaint, which may include contacting the complainant,
respondent, and/or potential witnesses. However, if the form is incomplete or does not contain specific
information, the College’s evaluation, any investigation and/or response may be limited.
Submit the completed form to Megan Pylican, Deputy Title IX Coordinator or Camilla Glatt, Title IX/EEO
Coordinator. You may submit this form electronically using the “Submit” button at the bottom of this form, drop
this form off in the Human Resources Office located in the A, Building, or by mailing the form to 2600 N 20
Pasco, WA 99301.
Are you a: ☐ nt ☐
Employee Stude ☐Faculty ☐Visitor ☐Other (please specify)
If you wish to identify yourself, please fill in the information listed below:
Last Name: ____________________________________________ First Name: ___________________________________________________
City:_________________________________________________ State: __________________________ Zip ________________
Contact Number: _______________________________________ E-mail: ________________________________________________________
Type and Basis of Complaint:
Type of Complaint: ☐
Discrimination ☐Harassment (including sexual misconduct) ☐Retaliation
If you are filing a discrimination or harassment complaint, please indicate the protected status(s) that is/are the
basis for the alleged behavior:
☐Race/Ethnicity ☐Nationality ☐Sex/Gender ☐Age ☐Marital Status ☐Pregnancy ☐ n
Sexual Orientation ☐Genetic Predisposition ☐Veteran Status ☐Disability ☐Dog Guide/Service Animal