This form is to be used for filing a complaint alleging discrimination on the basis of age, ancestry, color, disability, national origin, race, religious creed, gender, sexual orientation, or veteran status.

Please respond to each of the following items.

1. ______________________________________________________________________________________________________
   Name

2. ______________________________________________________________________________________________________
   Street Address                                                     City                           State                    Zip Code

3. Telephone numbers:

   __________________________________________________
   Home Phone           Cell Phone

4. ____________________________________
   Social Security Number

5. ____________________________________
   Date of Birth

6. What is the specific incident(s) that has caused you to file a discrimination grievance? Please describe in detail relevant information including person involved, times, dates, places, witnesses, and, if applicable, any college activity(ies) involved.

    

    

    

    

7. Date(s) when alleged incident(s) first occurred.

   _________________________________
   Month       Day     Year

8. Did you attempt to resolve the complaint by contacting the individual(s) against whom the grievance is directed?

   ________ ________
   Yes No

9. Describe what steps were taken to resolve the complaint, and the result of those steps. Include persons involved, times, dates, places, and witnesses.

 

 

 

 

 

I understand that submission of this form grants the Affirmative Action Officer my permission to conduct a full investigation of the above complaint. This investigation may involve review of confidential documents and interviews with relevant persons, including college employees and other witnesses.

 

 

________________________________________________________________________________________
Signature

________________________________________________________________________________________
Witness

____________________________
Date

Office Use Only:

Date of Receipt: _________________________

Received by: ________________________________________________________