Century College Office of Diversity and Inclusion Complaint Form 1
Office Diversity and Inclusion (ODI)
Discrimination/Harassment
Complaint Form
Name of Complainant:
Date:
Address:
City:
State:
Zip Code:
Work Phone:
Cell Phone:
Email:
Gender:
(please specify)
Your Status:
Student
Faculty/Staff
External (Non-Campus)
Type of Complaint:
Discrimination
Harassment
Retaliation
I was discriminated/harassed/retaliated against on the basis of my:
Age
Color
Creed
Disability
Familial Status (employment)
Gender Expression
Gender Identity
National Origin
Race
Reliance on Public Assistance
Sex (including pregnancy and sexual harassment)
Religion
Sexual Orientation
Other federal or state protected class (specify)
Marital Status
Membership or Activity in a Local Commission
(employment)
I was:
harassed/intimidated
laid off
treated differently
retaliated against after filing or participating in a
discrimination/ harassment complaint
warned/suspended
denied reasonable accommodations
not hired
denied services
denied a raise
denied religious accommodations
given a poor performance evaluation
given a poor grade/evaluation
(student)
given less training opportunities
physically assaulted
delegated difficult duties
Denied membership in a student club
denied promotion
Other:
Century College Office of Diversity and Inclusion Complaint Form 2
I believe that I was discriminated/harassed/retaliated against by the following person(s), referred to as respondent.
Please provide as much information as possible.
Name of Respondent 1:
Address:
City:
State:
Zip Code:
Gender:
Other:
Work Phone:
Cell Phone:
Status:
Student
Faculty
Staff
External (Non-campus)
Specify
Name of Respondent 2:
Address:
City:
State:
Zip Code:
Gender:
Other:
Work Phone:
Cell Phone:
Status:
Student
Faculty
Staff
External (Non-campus)
Specify
Name of Witness 1:
Address:
City:
State:
Zip Code:
Gender:
Other:
Work Phone:
Cell Phone:
Status:
Student
Faculty
Staff
External (Non-campus)
Specify
Century College Office of Diversity and Inclusion Complaint Form 3
Name of Witness 2:
Address:
City:
State:
Zip Code:
Gender:
Other:
Work Phone:
Cell Phone:
Status:
Student
Faculty
Staff
External (Non-campus)
Specify
Name of Witness 3:
Address:
City:
State:
Zip Code:
Gender:
Other:
Work Phone:
Cell Phone:
Status:
Student
Faculty
Staff
External (Non-campus)
Specify
Name of Witness 4:
Address:
City:
State:
Zip Code:
Gender:
Other:
Work Phone:
Cell Phone:
Status:
Student
Faculty
Staff
External (Non-campus)
Specify
Century College Office of Diversity and Inclusion Complaint Form 4
Explain your complaint in detail. Add additional pages if necessary and attach documents you believe may be helpful
in investigating your complaint.
1. Describe the specific incident(s) of discrimination/harassment/retaliation. List dates, times, 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 e.g., race, age, sex, disability.
3. Provide the names and titles of people you believe were treated more favorably than you due to your protected
class status. If known, list the protected class status, e.g., race, age, sex, disability of each person.
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
If more space is needed, please attach to this form.
Century College Office of Diversity and Inclusion Complaint Form 5
List documents you believe may help investigate 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 content:
Name of document 2:
Date:
Explanation of content:
Century College Office of Diversity and Inclusion Complaint Form 6
Name of document 3:
Date:
Explanation of content:
Name of document 4:
Date:
Explanation of content:
Century College Office of Diversity and Inclusion Complaint Form 7
Remedy Sought:
Signature:
Date:
Please return form to:
Century College
Rosa Rodriguez, Chief Diversity Officer
Office of Diversity and Inclusion
President's Office, Room 2500
3300 Century Ave. North
White Bear Lake, MN 55110
rosa.rodriguez@century.edu
651-779-5786
If you have additional questions or to schedule an appointment, call 651-779-5786.
This form may be mailed, emailed or hand-delivered to the Office of Diversity and Inclusion.
Assistance in completing this form is provided by calling 651-779-5786.
Century College is a member of Minnesota State Colleges and Universities. We are an affirmative action, equal opportunity employer and
educator. This document can be available in alternative formats to individuals with disabilities by calling 651.773.1745 or emailing
access.center@century.edu.
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