Fillable Internal Non-Discrimination Complaint Intake Form (University of Baltimore)

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Internal Non-Discrimination Complaint Intake Form (University of Baltimore)

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UB Non-Discrimination Complaint Number
Internal Non-Discrimination Complaint Intake Form
This compliant form is to be utilized for reporting conduct that is believed to be in violation of University of Baltimore's
Non-Discrimination Policy and Procedures - Complaints of Discrimination Against Non-Students.
1. COMPLAINANT – Person who alleges the violation of
Non-Discrimination policy:
Last Name
First Name
Pri
mary Role Faculty Student Third Party
on Campus:
Staff Other, please state:
Positio
n / Title
School / Dept.
Home Address
City State Zip Code
Phone Number
Email
RESPONDENT – Person you believe to be responsible for
the alleged violation of Non-Discrimination policy:
Last Name
First Name
Pri
mary Role Faculty Student Third Party
on Campus:
Staff Other, please state:
Positio
n / Title
School / Dept.
Home Address
City State Zip Code
Phone Number
Email
2. BASIS OF YOUR COMPLAINT: What is the reason for your claim of discrimination? (Please check all applicable items.)
Age Ancestry Color Disability Gender Expression
Gender Identity Genetic Information Harassment Marital Status National Origin
Political Affiliation Pregnancy Race/Ethnicity Religion Reprisal/Retaliation
Sex Sexual Harassment Sexual Misconduct Sexual Orientation Title IX
Veteran Status Other, please state:
If you che
cked color, religion or national origin, please specify:
If you checked genetic information, how did the Respondent obtain the genetic information:
What type of genetic information is involved: genetic testing family medical history genetic services
Page 1 of 4
3. ADVERSE ACTION AGAINST YOU: Indicate action(s) you believe the Respondent(s) took or failed to take because of age, ancestry,
color, disability, gender expression/identity, genetic information, marital status, national origin, political affiliation, pregnancy,
race/ethnicity, religion, sex, sexual harassment/misconduct/orientation, Title IX, veteran status, or other protected category.
(Please check all applicable items.)
Academic Grievance Access to Program/Activity Accommodation to Disability Award
Bullying Demotion Evaluation
Exclusion from Program /Activity
Grade Assignment Harassment Hazing Hiring
Intimidation Job Assignment Job Benefits Layoff
Pregnancy Leave Promotion Recall Religious Observance
Segregated Facilities Seniority Suspension Termination
Testing Training Wages Working Conditions
Other, please state:
4. INFORMATION ABOUT THE INCIDENT(S): Provide general information about your allegations.
Date conduct occurred: (Please provide the date of the last alleged act of discrimination.)
Number of Incidents: Name of Supervisor or Manager aware of your allegations:
Witness 1 : Name Title/Role/Department:
Witness 2: Name Title/Role/Department:
Witness 3 : Name Title/Role/Department:
Witness 4: Name Title/Role/Department:
Witness 5 : Name Title/Role/Department:
5. NATURE OF THE COMPLAINT: Explain as briefly and clearly as you can what happened and how you believe you were
discriminated/retaliated against. Please be sure to include the following, at a minimum:
• Why you believe you were discriminated/retaliated against;
• What harm, if any, was caused to you or others as a result of the alleged discriminatory act(s);
• Dates, places, names and titles or persons involved and witnesses, if any;
• How you believe other persons were treated differently from you;
• What explanation, if any, was offered for the act(s) by the Respondent(s);
• Attach any written documentation pertaining to this matter.
If this complaint is based on disability, please describe the disability, your history of disability, or why you think you were/are
regarded as disabled.
Page 2 of 4
I believe that I have been subjected to a discriminatory practice because (if necessary, attach additional sheets):
Page 3 of 4
6. RELIEF SOUGHT: What remedy(ies) do you seek to resolve this complaint to your satisfaction? (i.e., stop inappropriate behavior
reinstatement of job or status in academic program, removal of discipline, change or removal of academic record or grade, etc.)
7. SIGNATURE AND VERIFICATION: I affirm that, to the best of my knowledge or belief, the information contain herein is true and
factual. Additionally, I understand that the effective date of filing this compliant is the date this form is physically received by the
UB's Office of Human Resources. I further understand that any person who knowingly provides frivolous, false or fraudulent
information in a Non-Discrimination complaint may be subject to discipline. If applicable, I hereby authorize the release of any
medical information needed for the investigation.
Signature of Complainant: Date:
Received by: List all attachments received with form:
Signature:
Received date:
Respondent(s) notification date:
Investigative Report/Decision date:
Was Report/Decision Appealed? Yes No
Appeal date:
Final Decision Date:
Complaint Filed with External Agency? Yes No
Agency’s Name: Date:
Page 4 of 4
OFFICE OF HUMAN RESOURCES USE ONLY:
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Internal Non-Discrimination Complaint Intake Form (University of Baltimore)

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Completed 28 August 2020

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