Fillable STUDENT COMPLAINT FORM Redwoods Community College District provides (College of the Redwoods)

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STUDENT COMPLAINT FORM Redwoods Community College District provides (College of the Redwoods)

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  • 25 check-boxes
  • 52 other fields

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File type: PDF

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STUDENT COMPLAINT
FORM
CR Campus
Work Phone
Last Name First Name MI
Mailing
Address
City
Cell Phone
Home Phone
Best time to call:
AM/PM
State Zip Code
E-mail
Yes
No
Currently a CR Student?
Was Early Resolution sought?
Yes
No
If yes, with whom: Date
Indicate the type(s) of complaint being filed:
Discrimination
Harassment Retaliation
Sexual Misconduct Dating Violence Domestic Violence Stalking
If you are filing a Discrimination or Harassment complaint, indicate the protected status(es) that was/were the basis(es) of the alleged
Discrimination or Harassment. (Please select all that apply):
Race/Color
National Origin/Ancestry
Marital Status
Religion
Gender/Sex
Gender Identity/Expression
Sexual Orientation
Disability
Military/Veteran Status
Medical Condition
Genetic Information
Age
.
Page 1 of 3
Redwoods Community College District provides a procedure for filing and processing complaints of unlawful discrimination and
harassment. These policies and procedures incorporate the legal principles contained in nondiscrimination provisions of the
California Code of Regulations, title 5, sections 59300 et seq. as well as other state and federal substantive and procedural
requirements.
Please complete this form to the best of your ability. Once completed please click on "Submit" and this form will automatically
be emailed to Wendy Bates, Title IX Coordinator. You will receive a response within 48 hours. You can also mail the form to:
College of the Redwoods, Attn: Wendy Bates, Title IX Coordinator, 7351 Tompkins Hill Road, Eureka, CA, 95501.
Student ID Number: ____________
____________
Submit
STUDENT COMPLAINT FORM
1. Identify the Respondent(s) against whom your complaint is made. For each Respondent, provide the identifying information
requested below.
Respondent(s) name:
Association with the campus:
Association to you:
2. Describe the incident(s) or events(s), date(s), time(s), and location(s) giving rise to your complaint.
Attach add
itional pages to this form, if necessary.
3. Describe the specific harm you have suffered resulting from the incident(s). Attach additional pages to this form, if necessary.
4. What did you or
others do to try to resolve the complaint? What was the outcome?
Page 2 of 3
STUDENT COMPLAINT FORM
5.
Identify
individuals
who
may
have
observed
or
witnessed
the
incident(s)
that
you
described.
Last Name First Name MI
Telephone
E-mail
Last
Name First Name MI
Position/
Job Title
E-mail
Cell Phone
Telephone
Cell Phone
6. Do you have any documents or electronic communications (including text messages or email) that support your complaint?
Yes
No
(Please list and attach a copy.)
7. Do you ha
ve any physical evidence (such as photographs, videos, blood tests or rape kits) that support your complaint? (Please describe)
8. Describ
e the outcome(s) you expect from filing your complaint. Be as specific as possible.
You may elect to have an Advisor present at meeting(s) and/or interview(s) which may be a Sexual Assault Victim’s Advocate. If you
indicate you will have an Advisor, you are authorizing that individual to accompany you to any meeting(s) and/or interview(s) regarding
this complaint. The role of the Advisor is limited to observing and consulting with you.
9. If you will be accompanied by an Advisor, provide the name and telephone number.
Last Name
First Name
MI
Telephone
CERTIFICATION
Cell Phone
I certify that the information given in this complaint is true and correct to the best of my knowledge or belief.
Print Name of Student
Signature of Student
Date
For
CR Use
Only:
Date
Complaint
Received
Signature
Page 3 of 3
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STUDENT COMPLAINT FORM Redwoods Community College District provides (College of the Redwoods)

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Completed 3 September 2020

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