Fillable Minnesota State Colleges and Universities Discrimination/Harassment Complaint Form (Anoka Technical College)

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Minnesota State Colleges and Universities Discrimination/Harassment Complaint Form (Anoka Technical College)

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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

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

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.

____________________________________________________________________________________________

______________________________

____________________________________________________________________________________________

________________________________________________________________________

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? ___________________________________________

______________________________________________________________________________

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? ___________________________________________

______________________________________________________________________________

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? ___________________________________________

______________________________________________________________________________

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: _______________________________

____________________________________________________________________________________________

NAME OF DOCUMENT #2: ____________________________________________________________________

DATE: _________________________ EXPLANATION OF CONTENTS: _______________________________

____________________________________________________________________________________________

NAME OF DOCUMENT #3: ____________________________________________________________________

DATE: _________________________ EXPLANATION OF CONTENTS: _______________________________

____________________________________________________________________________________________

EXPLANATION OF CONTENTS:

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Minnesota State Colleges and Universities DiscriminationHarassment Complaint Form (Anoka Technical College)

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Completed 26 July 2020

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