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.
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