SUNY - NASSAU COMMUNITY COLLEGE
COMPLAINT FORM
This form is to be used to file a charge of discrimination and/or harassment based on RACE, COLOR, RELIGION, SEX, NATIONAL ORIGIN,
AGE, DISABILITY, MARITAL STATUS, SEXUAL HARASSMENT, SEXUAL VIOLENCE
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1. Your Name ____________________________________________ ID# ______________________________
2. Preferred Contact # ____________________
Faculty ( ) Staff ( ) Student ( ) Other ( ) __________________________
______________________ _________________________
Department Supervisor
Home Address ____________________________________________________________________________________
Street City State Zip Code
_____________________________________________________________________________________________
1. Alleged discrimination was based on: Age ( ) Bullying ( ) Disability ( ) Marital Status ( )
Military/Veteran Status ( ) National Origin ( ) Sexual Harassment/Violence ( ) Race or Color ( ) Religion ( ) Sex ( )
Sexual Harassment/Violence ( ) Other ( )
2. Alleged discrimination took place on or about: ___________________________
Month/day/year
Location: _____________________________________________________
a. Have you filed this charge with a Federal, State or Local Government? Yes ( ) No ( )
If yes, please indicate agency and date: _______________________________________________________
b. Have you instituted a suit or court action on this charge? Yes ( ) No ( )
If yes, please indicate: ____________________________________________________________________
3.
Is the alleged discrimination still continuing? Yes ( ) No ( )
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Rev. 10/2018 - Office of Equity, Inclusion & Affirmative Action, ADA/504 & Title IX
4. Respondent (Accused) ________________________________________________________________________________
(add additional page if multiple Respondents)
5. Witness names and contact information (if any) _________________________________________________________________
6. Please state the type of action that you would like to see end the situation. ________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
________________________________________________________________________________________________________
7.
Describe briefly the act which occurred and the reason for concluding that it was discriminatory (use extra sheet if
necessary) _________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
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8.
I swear or affirm that I have read the above charge and that it is true to the best of my knowledge, information, belief
and this is not a frivolous or malicious complaint.
Date ________________________ _______________________________________
(Sign your name)
click to sign
signature
click to edit
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