Fillable Harassment, Discrimination (Including Sexual Misconduct) and Retaliation Complaint (Columbia Basin College)

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Harassment, Discrimination (Including Sexual Misconduct) and Retaliation Complaint (Columbia Basin College)

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Harassment, Discrimination (Including Sexual Misconduct) and
Retaliation
Complaint Form
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
th
Ave,
Pasco, WA 99301.
Complainant Information:
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: ___________________________________________________
Address: ____________________________________________________________________________________________________________________
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
☐
Religio
Sexual Orientation ☐Genetic Predisposition ☐Veteran Status ☐Disability ☐Dog Guide/Service Animal
Respondent/Accused Information:
Please identify the person against whom your complaint is made:
Name: ____
___________
_______________________________________ Contact Information: _________________________________
Is this person a: ☐ Student ☐Employee ☐Faculty ☐Visitor ☐Other (please specify)
Title/Department (if applicable): _________________________________________________________________________________________
Relationship/Association to you: _________________________________________________________________________________________
Complaint: While providing details is essential to evalu
ating and/or investigating your complaint, please
be advised that some or all of the information you provide in this section may be shared with the
respondent(s).
1. Describe the incident(s)/event(s) including dates, times, locations, and any potential witnesses to the
behavior:
2. Des
cribe the impact the behavior has had on you:
3. Have you taken any action to stop the behavior? ☐Yes ☐No
If so, what actions have you taken and what was the outcome?
4. Please add any additional documents or information that supports your complaint.
Resolution:
What remedy are you seeking?
By submitting this form, I certify that the information I have provided is true and accurate to the best of
my knowledge.
_____________________________________________________________ _______________________________________________
Signature Date
_____________________________________________________________ _______________________________________________
Telephone Number (Optional) Relationship to Complainant (Optional)
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Harassment, Discrimination (Including Sexual Misconduct) and Retaliation Complaint (Columbia Basin College)

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Completed 21 July 2020

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