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Minnesota State Colleges and Universities
Discrimination/Harassment Complaint Form
Date: __________________________
Name of COMPLAINANT: _______________________________________________________
(if more than one complainant, complete intake form for each)
Address (local): ________________________________________________________________
Address (residence): ____________________________________________________________
City: ___________________________________ State: _________ Zip: ___________________
Phone: (work) ______________________________ (home) _____________________________
Status: Student Faculty Staff Administrator External/Non-Campus
TYPE OF COMPLAINT: DISCRIMINATION HARASSMENT RETALIATION
I WAS DISCRIMINATED/HARASSED/RETALIATED AGAINST ON THE BASIS OF MY:
Race Age Reliance on Public Assistance
Sex National Origin Sexual Orientation
Color Disability Marital Status
Creed Religion Membership/Activity in Local Commission
Gender Identity Gender Expression
I believe I was discriminated/harassed/retaliated against by:
Name of RESPONDENT: ________________________________________________________
(if more than one respondent, list complete information for each)
Address (local): ________________________________________________________________
Address (residence): ____________________________________________________________
City: ___________________________________ State: _________ Zip: ___________________
Phone: (work) ______________________________ (home) _____________________________
Status: Student Faculty Staff Administrator External/Non-Campus
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Name of RESPONDENT #2: _____________________________________________________
(if more than one respondent, list complete information for each)
Address (local): ________________________________________________________________
Address (residence): ____________________________________________________________
City: ___________________________________ State: _________ Zip: ___________________
Phone: (work) ______________________________ (home) _____________________________
Status: Student Faculty Staff Administrator External/Non-Campus
Name of RESPONDENT #3: ______________________________________________________
(if more than one respondent, list complete information for each)
Address (local): ________________________________________________________________
Address (residence): ____________________________________________________________
City: ___________________________________ State: _________ Zip: ___________________
Phone: (work) ______________________________ (home) _____________________________
Status: Student Faculty Staff Administrator External/Non-Campus
Name of RESPONDENT #4: ______________________________________________________
(if more than one respondent, list complete information for each)
Address (local): ________________________________________________________________
Address (residence): ____________________________________________________________
City: ___________________________________ State: _________ Zip: ___________________
Phone: (work) ______________________________ (home) _____________________________
Status: Student Faculty Staff Administrator External/Non-Campus
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EXPLAIN YOUR COMPLAINT IN DETAIL. INCLUDE THE FOLLOWING INFORMATION. ADD
ADDITIONAL PAGES IF NECESSARY. ATTACH DOCUMENTS YOU BELIEVE MAY BE HELPFUL IN
INVESTIGATING YOUR COMPLAINT.
1. Describe the specific incident(s) of discrimination/harassment/retaliation. List times, dates, locations, names
and titles of the people involved in the incident(s).
2. Explain why you believe that you were discriminated/harassed/retaliated against because of your protected
class status (race, age, gender, disability, etc.).
3. Provide the names and titles of people you believe were treated more favorably than you due to your
protected class status. List the protected class status (race, age, gender, disability, etc.) of each person.
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LIST POTENTIAL WITNESSES YOU BELIEVE POSSESS INFORMATION ABOUT YOUR COMPLAINT.
ADD ADDITIONAL PAGES IF NECESSARY.
Name of WITNESS #1: ______________________________________________________
(if more than one witness, list complete information for each)
Address (local): ________________________________________________________________
Address (residence): ____________________________________________________________
City: ___________________________________ State: _________ Zip: ___________________
Phone: (work) ______________________________ (home) _____________________________
What information can this witness provide? ___________________________________________
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Name of WITNESS #2: ______________________________________________________
(if more than one witness, list complete information for each)
Address (local): ________________________________________________________________
Address (residence): ____________________________________________________________
City: ___________________________________ State: _________ Zip: ___________________
Phone: (work) ______________________________ (home) _____________________________
What information can this witness provide? ___________________________________________
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Name of WITNESS #3: ______________________________________________________
(if more than one witness, list complete information for each)
Address (local): ________________________________________________________________
Address (residence): ____________________________________________________________
City: ___________________________________ State: _________ Zip: ___________________
Phone: (work) ______________________________ (home) _____________________________
What information can this witness provide? ___________________________________________
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LIST DOCUMENTS YOU BELIEVE MAY HELP IN INVESTIGATING YOUR COMPLAINT. PROVIDE THE
NAME, DATE AND EXPLANATION OF THE CONTENTS OF EACH DOCUMENT. ADD MORE PAGES IF
NECESSARY.
NAME OF DOCUMENT #1: ____________________________________________________________________
DATE: _________________________ EXPLANATION OF CONTENTS: _______________________________
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NAME OF DOCUMENT #2: ____________________________________________________________________
DATE: _________________________ EXPLANATION OF CONTENTS: _______________________________
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NAME OF DOCUMENT #3: ____________________________________________________________________
DATE: _________________________ EXPLANATION OF CONTENTS: _______________________________
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EXPLANATION OF CONTENTS:
EXPLANATION OF CONTENTS:
EXPLANATION OF CONTENTS:
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