This form is designed to assist you with filing a discrimination and/or harassment complaint. Please write clearly and focus on the alleged discriminatory and/or harassing conduct. The complaint should include as much information regarding the incident giving rise to the complaint as possible, including the location, date and time of the alleged incident(s); the name of the individual or group whom the complaint is against, if known; the name of any witnesses of which you are aware, if known; a description of the incident(s); and the remedy sought.

 

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Name filing the complaint

Date

 

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Signature

Date

 

You may use the back side of this sheet if needed.

* Please return this form to the Title IX/EEO coordinator.