complain-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

Name of Alleged Harasser: *
Enter the name. Required.

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

Female
Male
Undergraduate Student
Graduate Student
Staff
Faculty
Other

Your external phone number: *
Enter your external phone number. You will enter your email address below. Required.

Your external address: *
Enter your external address. You will enter your email address below. Required.

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
National Origin
Gender
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: *
Please list the sequence of events, including names and addresses of witnesses, as well as any relevant facts and statements. Required.

How can this be resolved? *
What would you like to see happen to resolve this issue? Required.

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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