Complaint Form - Office of Equal Opportunity, Diversity & Outreach

Your Name: *
Enter your name. Required.

You are a(n):*
Check all that apply. Required

Female
Male
Undergraduate Student
Graduate Student
Staff
Faculty
Other

Alleged Harasser: *

He/She is a(n): *
Check all that apply. Required.

Female
Male
Undergraduate Student
Graduate Student
Staff
Faculty
Other

Your phone number: *

Your address: *
Enter your campus and/or external address. You will enter your email address below. Required.

Campus address:

Street:
City:
State:
Zip Code:

Type(s) of alleged discrimination/harassment: *
Check all that apply. You may consult the laws and definitions (opens in new window). Required.

Age
Disability
Gender
National Origin
Race or color
Religion
Retaliation
Sexual Harassment
Sexual Orientation
Veteran Satus
Other:

Date(s) on which alleged discrimination/harassment occurred: *
Required.

Additional persons involved:
List any other employees, persons, or students involved. Leave blank if no others were involved.

Additional complaints filed? *
Indicate if you have filed a complaint with any other enforcement agency. If you have, enter the agency or agencies you filed with. Required.

No
Yes, with:

Description of Complaint: *
Briefly describe the act which occurred and your reason for concluding that it was discriminatory � please list the sequence of events, as well as any relevant facts and statements. Please state what you would like to see happen to resolve this issue.

The above information is complete and accurate to the best of my knowledge and belief and I hereby elect to use the procedures outlined in the Equal Opportunity and Anti-Harassment Complaint Procedures. This information will be maintained confidentially to the extent practicable under the circumstances.

Your email address: *
Enter your email address. Required.

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Equal Opportunity and Anti-Harassment Complaint Form

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