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Non-Discrimination & Harassment Policy and

Grievance Procedure

Revised 10/02, 08/04, 06/05, 03/06, 11/07

June 2015

Human Resources

Administrative Policy & Procedure 3-140 Page 1 of 14

Columbia Basin College recognizes its responsibility for investigation, resolution, implementation of

corrective measures, and monitoring the educational environment and workplace to stop, remediate, and

prevent discrimination on the basis of race, color, national origin, age, perceived or actual physical or mental

disability, pregnancy, genetic information, sex, sexual orientation, gender identity, marital status, creed,

religion, honorably discharged veteran or military status, or use of a trained guide dog or service animal, as

required by Title VI of the Civil Rights Act of 1964, Title VII of the Civil Rights Act of 1964, Title IX of

the Educational Amendments of 1972, Sections 504 and 508 of the Rehabilitation Act of 1973, the

Americans with Disabilities Act and ADA Amendment Act, the Age Discrimination Act of 1975, the

Violence Against Women Reauthorization Act and Washington State’s Law Against Discrimination,

Chapter 49.60 RCW and their implementing regulations. To this end, Columbia Basin College (the

College) has enacted this policy prohibiting discrimination against and harassment of members of these

protected classes. Any individual found to be in violation of this policy will be subject to disciplinary action

up to and including dismissal from the College or from employment.

1.0 Objective and Responsibilities

Any employee, student, applicant, or visitor who believes that he or she has been the subject of

discrimination or harassment based on protected class status or gender should report the incident

or incidents to the College’s Title IX/EEO Coordinator identified below. If the complaint is against

that Coordinator, or his or her relative attending or working for the College, the complainant should

report the matter to the President’s office for referral to an alternate designee.

Name: Camilla Glatt, Vice President for Human Resources & Legal Affairs

Title: Title IX/EEO Coordinator

Office: Human Resources Contact Info: (509) 542-5548

The Title IX/EEO Coordinator or designee:

 Will accept all complaints and referrals from College employees, applicants, students, and

visitors.

 Will make determinations regarding how to handle requests by complainants for

confidentiality.

 Will keep accurate records of all complaints and referrals for the required time period.

 May conduct investigations or delegate and oversee investigations conducted by a

designee.

 May impose interim remedial measures to protect parties during investigations of

discrimination or harassment.

 Will issue written findings and recommendations upon completion of an investigation.

 May recommend specific corrective measures to stop, remediate, and prevent the

recurrence of inappropriate conduct.

The College encourages the timely reporting of any incidents of discrimination or harassment.

Complaints may be submitted in writing or orally. For complainants who wish to submit a written

complaint, a formal complaint form is available online at

https://www.columbiabasin.edu/index.aspx?page=907

. Hardcopies of the Policy and complaint

form are available at the following locations on campus: Hawk Central, Counseling & Advising

Center, Human Resources/Student Employment, President’s Office/Administrative Wing of A

Building and Vice President for Instruction’s Office.

2.0 Definitions

The following definitions are specific to the terms of this procedure and do not modify or revise

similar terms as used in related procedures or collective bargaining agreements.

2.1 Advisor: a person of the complainant or respondent’s choosing who can accompany the

complainant or respondent to any related meeting or proceeding.

2.2 Complainant: employee(s), applicant(s), student(s), or visitor(s) of Columbia Basin

College who alleges that she or he has been subjected to discrimination or harassment due

to his or her membership in a protected class.

2.3 Complaint: a description of facts that allege violation of the College’s policy against

discrimination or harassment.

2.4 Consent: knowing, voluntary and clear permission by word or action, to engage in

mutually agreed upon sexual activity. Each party has the responsibility to make certain

that the other has consented before engaging in the activity. For consent to be valid, there

must be at the time of the act of sexual intercourse or sexual contact actual words or conduct

indicating freely given agreement to have sexual intercourse or sexual contact. In order to

give effective consent one must be of legal age.

A person cannot consent if he or she is unable to understand what is happening or is

disoriented, helpless, asleep or unconscious for any reason, including due to alcohol or

other drugs. An individual who engages in sexual activity when the individual knows, or

should know, that the other person is physically or mentally incapacitated has engaged in

nonconsensual conduct.

Intoxication is not a defense against allegations that an individual has engaged in

nonconsensual sexual conduct.

2.5 Discrimination: unfavorable treatment of a person based on that person’s membership or

perceived membership in a protected class. Harassment is a form of discrimination.

2.6 Force: use of physical violence and/or imposing on someone physically to gain sexual

access. Force also includes threats, intimidation and coercion that overcome resistance or

produce consent. Sexual activity that is forced is by definition non-consensual, but non-

consensual sexual activity is not by definition forced.

2.7 Harassment: a form of discrimination consisting of physical or verbal conduct that

denigrates or shows hostility toward an individual because of their membership in a

protected class or their perceived membership in a protected class. Harassment occurs

when the conduct is sufficiently severe and/or pervasive and so objectively offensive that

it has the effect of altering the terms or conditions of employment or substantially limiting

the ability of a student to participate in or benefit from the College’s educational and/or

social programs. Petty slights, annoyances, offensive utterances, and isolated incidents

(unless extremely serious) typically do not qualify as harassment.

Examples of conduct that could rise to the level of discriminatory harassment include but

are not limited to the following:

 Epithets, "jokes," ridicule, mockery or other offensive or derogatory conduct

focused upon an individual's membership in a protected class.

 Verbal or physical threats of violence or physical contact directed towards an

individual based upon their membership in a protected class.

 Making, posting, emailing, texting, or otherwise circulating demeaning or

offensive pictures, cartoons, graffiti, notes or other materials that relate to race,

ethnic origin, gender or any other protected class.

2.8 Hazing: acts likely to cause physical or psychological harm or social ostracism to any

person within the College community, when related to admission, initiation, joining, or any

other group – affiliation activity.

2.9 Hostile Environment: any situation in which there is harassing conduct that is based on

protected class status and is sufficiently severe and/or pervasive and so objectively

offensive that it has the effect of altering the terms or conditions of employment or

substantially limiting the ability of a student to participate in or benefit from the College’s

educational or social programs.

The determination of whether an environment is “hostile” must be based on all of the

circumstances. These circumstances could include:

 The frequency of the conduct;

 The nature and severity of the conduct;

 Whether the conduct was physically threatening;

 Whether the conduct was directed at more than one person;

 Whether the conduct arose in the context of other discriminatory conduct;

 Whether the statement is a mere utterance of an epithet which engenders offense

in an employee or student, or offends by mere discourtesy or rudeness;

 Whether the speech or conduct deserves the protections of academic freedom or

the 1

Amendment.

2.10 Protected Class: persons who are protected under state or federal civil rights laws,

including laws that prohibit discrimination on the basis of race, color, national origin, age,

perceived or actual physical or mental disability, pregnancy, genetic information, sex,

sexual orientation, gender identity, marital status, creed, religion, honorably discharged

veteran or military status, or use of a trained guide dog or service animal.

2.11 Resolution: the means by which the complaint is finally addressed. This may be

accomplished through informal or formal processes, including counseling, mediation

(when appropriate), or the formal imposition of discipline sanction.

2.12 Respondent: person or persons who are members of the campus community who allegedly

discriminated against or harassed another person or persons.

2.13 Sexual Exploitation: occurs when one person takes non-consensual or abusive sexual

advantage of another for his/her own advantage or benefit, or to benefit or advantage

anyone other than the one being exploited, and that behavior does not otherwise constitute

one of other sexual misconduct offenses. Examples of sexual exploitation include, but are

not limited to: invasion of sexual privacy, engaging in voyeurism, non-consensual video or

audio taping of sexual activity; sexually-based stalking and/or bullying may also be forms

of sexual exploitation.

2.14 Sexual Harassment: a form of discrimination consisting of unwelcome, gender-based

verbal, written, electronic and/or physical conduct. Sexual harassment does not have to be

of a sexual nature, however, and can include offensive remarks about a person's gender.

There are two types of sexual harassment.

2.14.1 Hostile Environment Sexual Harassment occurs when the conduct is sufficiently

severe and/or pervasive and so objectively offensive that it has the effect of altering

the terms or conditions of employment or substantially limiting the ability of a

student to participate in or benefit from the College’s educational and/or social

programs.

2.14.2 Quid Pro Quo Sexual Harassment occurs when an individual in a position of real

or perceived authority, conditions the receipt of a benefit upon granting of sexual

favors.

Examples of conduct that may qualify as sexual harassment include:

 Persistent comments or questions of a sexual nature.

 A supervisor who gives an employee a raise in exchange for submitting to

sexual advances.

 An instructor who promises a student a better grade in exchange for sexual

favors.

 Sexually explicit statements, questions, jokes, or anecdotes.

 Unwelcome touching, patting, hugging, kissing, or brushing against an

individual's body.

 Remarks of a sexual nature about an individual's clothing, body, or

speculations about previous sexual experiences.

 Persistent, unwanted attempts to change a professional relationship to an

amorous relationship.

 Direct or indirect propositions for sexual activity.

 Unwelcome letters, emails, texts, telephone calls, or other communications

referring to or depicting sexual activities.

2.15 Sexual Violence: is a type of sexual discrimination and harassment. Nonconsensual sexual

intercourse, nonconsensual sexual contact, domestic violence, dating violence, and stalking

are all types of sexual violence.

2.16 Nonconsensual sexual intercourse: is any sexual intercourse (anal, oral, or vaginal),

however slight, with any object, by a person upon another person, that is without consent

and/or by force. Sexual intercourse includes anal or vaginal penetration by a penis, tongue,

finger, or object, or oral copulation by mouth to genital contact or genital to mouth contact.

2.17 Nonconsensual sexual contact: is any intentional sexual touching, however slight, with any

object, by a person upon another person that is without consent and/or by force. Sexual

touching includes any bodily contact with the breasts, groin, mouth, or other bodily orifice

of another individual, or any other bodily contact in a sexual manner.

2.18 Domestic violence: includes asserted violent misdemeanor and felony offenses committed

by the victim's current or former spouse, current or former cohabitant, person similarly

situated under domestic or family violence law, or anyone else protected under domestic

or family violence law.

2.19 Dating violence: means violence by a person who has been in a romantic or intimate

relationship with the victim. Whether there was such relationship will be gauged by its

length, type, and frequency of interaction.

2.20 Stalking: means intentional and repeated harassment or following of another person, which

places that person in reasonable fear that the perpetrator intends to injure, intimidate, or

harass that person. Stalking also includes instances where the perpetrator knows or

reasonably should know that the person is frightened, intimidated, or harassed, even if the

perpetrator lacks such intent.

3.0 Who May File a Complaint

Any employee, applicant, student or visitor of the College may file a complaint. Complaints may

be submitted in writing or verbally, which will be captured in written form for processing. The

College encourages the timely reporting of any incidents of discrimination or harassment. For

complainants who wish to submit a written complaint, a formal complaint form is available online

at https://www.columbiabasin.edu/index.aspx?page=907

. Hardcopies of the complaint form are

available at the following locations on campus: Hawk Central, Counseling & Advising Center,

Human Resources/Student Employment, President’s Office/Administrative Wing of A Building

and Vice President for Instruction’s Office. Any person submitting a discrimination complaint

shall be provided with a written copy of the College’s non-discrimination and harassment policies

and grievance procedures.

4.0 Confidentiality and Right to Privacy

Columbia Basin College will seek to protect the privacy of the complainant to the full extent

possible, consistent with the legal obligation to investigate, take appropriate remedial and/or

disciplinary action, and comply with the federal and state law, as well as Columbia Basin College

policies and procedures. Although Columbia Basin College will attempt to honor complainants’

requests for confidentiality, it cannot guarantee complete confidentiality. Determinations regarding

how to handle requests for confidentiality will be made by the Title IX/EEO Coordinator.

Confidentiality Requests and Sexual Violence Complaints. The Title IX/EEO Coordinator will

inform and obtain consent from the complainant before commencing an investigation into a sexual

violence complaint. If a sexual violence complainant asks that his or her name not be revealed to

the respondent or that the College not investigate the allegation, the Title IX/EEO Coordinator will

inform the complainant that maintaining confidentiality may limit the College’s ability to fully

respond to the allegations and that retaliation by the respondent and/or others is prohibited. If the

complainant still insists that his or her name not be disclosed or that the College not investigate,

the Title IX/EEO Coordinator will determine whether the College can honor the request and at the

same time maintain a safe and non-discriminatory environment for all members of the College

community, including the complainant.

Factors to be weighed during this determination may include, but are not limited to:

 The seriousness of the alleged sexual violence;

 The age of the complainant;

 Whether the sexual violence was perpetrated with a weapon;

 Whether the respondent has a history of committing acts of sexual violence or violence or

has been the subject of other sexual violence complaints;

 Whether the respondent threatened to commit additional acts of sexual violence against the

complainant or others; and

 Whether relevant evidence can be obtained through other means (e.g., security cameras,

other witnesses, physical evidence).

If the College is unable to honor a complainant’s request for confidentiality, the Title IX/EEO

Coordinator will notify the complainant of the decision and ensure that complainant’s identity is

disclosed only to the extent reasonably necessary to effectively conduct and complete the

investigation.

If the College decides not to conduct an investigation or take disciplinary action because of a

request for confidentiality, the Title IX/EEO Coordinator will evaluate whether other measures are

available to limit the effects of the harassment and prevent its recurrence and implement such

measures if reasonably feasible.

5.0 Responsible Employees and Reporting Responsibilities

The College is obligated to address acts of sex-based misconduct (including sexual harassment

and/or retaliation) of which a responsible employee knew or should have known occurred. A

“responsible employee” is any employee who:

 Has the authority to take action to redress sex-based misconduct;

 Has been given the duty of reporting incidents of sex-based misconduct or any other

misconduct by students; or

 A student could reasonably believe has this authority or duty.

For student complainants where the alleged offender is another student “responsible employees”

include administrators (Directors, Deans, Vice Presidents, etc.), Athletic Director/Assistant

Athletic Director, ASCBC Director/Assistant Director, Resource Center Staff, Completion

Coaches, Hawk Central Staff Members, Security Officers, and executive assistants and secretarial

staff reporting to positions designated above.

A responsible employee must report to the Title IX/EEO Coordinator all relevant details about

alleged sex-based misconduct (including sexual harassment and/or retaliation) that the student or

other person has shared and that the College will need to determine what occurred and resolve the

situation. This includes the names of the alleged Respondent (if known), the student complainant

or other person who experienced the alleged sex-based misconduct, others involved in the alleged

sex-based misconduct, as well as relevant facts, including the date, time and location. If the

complaint is against the Title IX/EEO Coordinator, or his or her relative attending or working for

the College, the complainant should report the matter directly to the President’s office for referral

to an alternate designee.

A responsible employee should provide the following information to a Complainant: (1) the

reporting obligations (discussed above) of the responsible employee; (2) Complainant’s option to

request confidentiality and available confidential resources; (3) Complainant’s right to file a Title

IX Complaint with the College; and (4) Complainant’s right to report a crime to local law

enforcement.

For convenience of student complaint reporting, there are College-designated responsible

employees and contact information noted on the College’s Webpage, with all reports referred by

the designated responsible employees to the Title IX/EEO Coordinator.

For a staff complaint of sex-based misconduct (including sexual harassment and/or retaliation) by

a student or another staff member, the staff complaint may be reported to the immediate supervisor,

with the supervisor report/referral to the Title IX/EEO Coordinator or the Human Resources

Director. A direct report to the Title IX/EEO Coordinator or Human Resources Director will be

more expeditious in terms of processing the complaint. If the complaint is against the Title IX/EEO

Coordinator, or his or her relative attending or working for the College, the complainant should

report the matter directly to the President’s office for referral to an alternate designee.

6.0 Investigation Procedure

Upon receiving a discrimination complaint, the Title IX/EEO Coordinator will assess the written

complaint and determine the appropriate steps necessary to ensure all relevant evidence is obtained

and all critical elements are addressed. The Title IX/EEO Coordinator shall be responsible for

overseeing all investigations. Investigations may be conducted by the Title IX/EEO Coordinator or

his or her designee. If the investigation is assigned to someone other than the Title IX/EEO

Coordinator, the Title IX/EEO Coordinator shall inform the complainant and respondent(s) of the

appointment of an investigator.

6.1 Interim Measures. The Title IX/EEO Coordinator may impose interim measures to protect

the complainant and/or respondent and/or others pending the conclusion of the

investigation. Interim measures may include, but are not limited to, imposition of no

contact orders, rescheduling classes, temporary work reassignments, referrals for

counseling or medical assistance, and imposition of summary discipline on the respondent

consistent with the College’s Student Conduct Code or the College’s employment policies

and collective bargaining agreements.

6.2 Investigation. Complaints shall be thoroughly and impartially investigated. The

investigation shall include, but is not limited to, interviewing the complainant and the

respondent, relevant witnesses, and reviewing relevant documents. The investigation shall

be concluded within a reasonable time, normally sixty days barring exigent circumstances.

At the conclusion of the investigation the investigator shall set forth his or her findings and

recommendations in writing. If the investigator is a designee, the investigator shall send a

copy of the findings and recommendations to the Title IX/EEO Coordinator. The Title

IX/EEO Coordinator shall consider the findings and recommendations and determine,

based on a preponderance of the evidence, whether a violation of the discrimination and

harassment policy occurred, and if so, what steps will be taken to resolve the complaint,

remedy the effects on any victim(s), and prevent its recurrence. Possible remedial steps

may include, but are not limited to, referral for voluntary training/counseling, development

of a remediation plan, limited contact orders, and referral and recommendation for formal

disciplinary action. Referrals for disciplinary action will be consistent with the Student

Conduct Code or College employment policies and collective bargaining agreements.

6.3 Written Notice of Decision. The Title IX/EEO Coordinator will provide each party and

the appropriate student services administrator or appointing authority with written notice

of the investigative findings and of actions taken or recommended to resolve the complaint,

subject to the following limitations.

6.3.1 Complainant Notice. The complainant shall be informed in writing of the findings

and of actions taken or recommended to resolve the complaint, if any, only to the

extent that such findings, actions or recommendations directly relate to the

complainant, such as a finding that the complaint is or is not meritorious or a

recommendation that the accused not contact the complainant. The complainant

may be notified generally that the matter has been referred for disciplinary action.

6.3.2 Respondent Notice. The respondent shall be informed in writing of the findings

and of actions taken or recommended to resolve the complaint and shall be notified

of referrals for disciplinary action.

6.3.3 Request for Reconsideration. Either the complainant or the respondent may seek

reconsideration of the finding and/or referral for disciplinary action to the Title

IX/EEO Coordinator. Requests for reconsideration shall be submitted in writing

to the Title IX/EEO Coordinator within seven days of receiving the decision.

Requests must specify which portion of the decision should be reconsidered and

the basis for reconsideration. If a request for reconsideration is received, the Title

IX/EEO Coordinator shall respond within 10 days. If the Title IX/EEO

Coordinator determines the request for reconsideration has merit, he or she may

issue an amended finding or referral. Any amended decision is final and no further

reconsideration is available, with the exception of Section 6.5 below for

appeal/review/grievance of disciplinary action as appropriate.

6.4 Informal Dispute Resolution. Informal dispute resolution processes, like mediation, may

be used to resolve complaints, when appropriate. Informal dispute resolution shall not be

used to resolve sexual discrimination complaints without written permission from both the

complainant and the respondent. If the parties elect to mediate a dispute, either party shall

be free to discontinue mediation at any time. In no event shall mediation be used to resolve

complaints involving allegations of sexual violence.

6.5 Appeal for Disciplinary Action. If formal disciplinary action is imposed as a result of a

finding of violation of this policy, then a respondent may file an appeal. The right to appeal

on particular grounds (i.e. the finding is not supported by the evidence, the sanction is

substantially disproportionate to the severity of the violation, due process was violated,

new evidence is available), if offered to either party, must be equally accessible to the

complainant.

6.5.1 Student Conduct Appeal. A student respondent may appeal a disciplinary action

taken by the Chief Student Conduct Officer or the Student Conduct Board in

accordance with WAC 132S-40-380. The complainant will receive notice of the

appeal and may submit either his/her own appeal or a written response to the

student respondent’s appeal within ten (10) calendar days, which will be

considered.

6.5.2 Represented Employee Grievance. A faculty member or represented classified

staff member may file a grievance under the applicable Collective Bargaining

Agreement.

6.5.3 Non-Represented Classified Employee Appeal. Non-represented classified staff

may file an appeal with the Personnel Resources Board under WAC 357-52-020.

6.5.4 All Other Employee Review. All other employees may request review of the

disciplinary action through the supervisory chain of command to the College

President within twenty (20) days of the imposition of the discipline. This includes

student workers if the discipline imposed resulted from conduct that occurred

during the performance of student employment and includes a loss in pay as a

sanction (nothing prohibits the Title IX/EEO Coordinator and/or Investigator from

referring findings against a student employee to the Chief Student Conduct Officer

for additional review under the Student Conduct Code). The request for review

must be a signed, written document articulating the grounds for review. The

responsible supervisor will respond to the request for review within twenty (20)

working days of receipt. If the finding(s) and/or discipline is upheld, then review

of the supervisor’s decision can be filed with the College President using the same

process. If the finding(s) and/or discipline is upheld, the College President’s

decision will constitute final action and there is no further appeal within the

College.

6.5.5 Volunteer or Visitor Review. A volunteer or visitor respondent may request

review of sanction(s) imposed in response to any findings under this Policy,

including temporary or permanent trespass through the President’s Office.

7.0 Publication of Anti-Discrimination Policies and Procedures

The policies and procedures regarding complaints of discrimination and harassment shall be

published and distributed as determined by the President or President's designee. Any person who

believes he or she has been subjected to discrimination in violation of College policy will be

provided a copy of these policies and procedures.

8.0 Limits to Authority

Nothing in this policy or procedure shall prevent the College President or designee from taking

immediate disciplinary action in accordance with Columbia Basin College policies and procedures,

collective bargaining agreement(s), and federal, state, and municipal rules and regulations.

Nothing in this policy or procedure limits the College from considering applicable policies of the

College when investigating complaints, including but not limited to, the College’s Standards of

Conduct policy, Appropriate Use of IT Resources policy, Code of Ethics policy, Consensual

Relations Leading to Conflicts of Interest policy or any other policy or procedure. For complaints

involving students, nothing in this policy or procedure limits the College from evaluating the

conduct of any student under the Student Code of Conduct.

9.0 Non-Retaliation, Intimidation and Coercion

Retaliation by, for or against any participant (including complainant, respondent, witness, Title

IX/EEO Coordinator, or investigator) is expressly prohibited. Retaliatory action of any kind taken

against individuals as a result of seeking redress under the applicable procedures or serving as a

witness in a subsequent investigation, or any resulting disciplinary proceedings is prohibited, and

is conduct subject to discipline. Any person who thinks he/she has been the victim of retaliation

should contact the Title IX/EEO Coordinator immediately.

10.0 Criminal Complaints

Discriminatory or harassing conduct may also be, or occur in conjunction with, criminal conduct.

Criminal complaints may be filed with the following law enforcement authorities:

Pasco CBC Campus: Pasco Police Department (509) 545-3481 or Emergency 911

Richland CBC Campus: Richland Police Department (509) 628-0333 or Emergency 911

The College will proceed with an investigation of harassment and discrimination complaints

regardless of whether the underlying conduct is subject to civil or criminal prosecution.

11.0 Other Discrimination Complaint Options

Discrimination complaints may also be filed with the following federal and state agencies:

Washington State Human Rights Commission:

http://www.hum.wa.gov/index.html

US Dept of Education Office for Civil Rights:

http://www2.ed.gov/about/offices/list/ocr/index.html

Equal Employment Opportunity Commission:

http://www.eeoc.gov/

Harassment, Discrimination (Including Sexual Misconduct) and Retaliation

Complaint Form

You should rev

iew 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 de

signed 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 req

uired 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 Camilla Glatt, Title IX/EEO Coordinator, A Building, Human Resources Office, 2600 N.

Avenue, Pasco, WA 99301 or cglatt@columbiabasin.edu

Complainant Information:

Are you a: ☐ Student ☐ Employee ☐ 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

☐ Religion

☐ 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 evaluating 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. Describe 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 a

dd any additional documents or information that supports your complaint.

Resolution:

What remedy are you seeking?

By submitt

ing 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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