Statement of Complaint

Name*

First Name

Last Name

Employer or Student ID#*

Date*

You are: *

Student Staff Faculty

Other:

Job Title*

Department*

Phone Number*

Email*

Person (or persons) you believe harassed you or discruminated againist you:

First Name

Last Name

Position

Department

Please explain the incident or conduct that is the basis of this complaint and include dates and where it took place.*

Describe the corrective action you are seeking.*

Suggested witness and contact information if known (email and telephone numbers if you have them):*

Would you like to seek mediation in order to resolve the complaint?*

Yes No

If no, please explain why:*

Do yo know of any documentation that may be relevant to this matter?*

Yes No

If yes, please upload any documents.

No File Chosen

File uploads may not work on some mobile devices.

Have you discussed this complaint with anyone else?*

Yes No

If yes, list their contact information below.

Signature:*