Social Equity Complaint Form

Unlawful Discrimination
Unlawful Discrimination based on: RaceColorReligionEthnicityGenderAgeNational OriginDisabilityVeteran's StatusRetaliation
Complainant's Background Information
Complainant Name:		EmployeeStudent
Home Address:				E-mail:
Campus Phone #:		Home Phone #:		Cell #:
If an Employee: Position/Title:		Department/Office & Location:
Bargaining Unit:		Work Ext.#:
Supervisor's Name:		Supervisor's Position/Title:
If a Student:	FreshmanSophomoreJuniorSeniorGraduate
Major:
Advisor's Name:		Advisor's Position/Title:
Respondent's Background Information (List as much information as known)
Respondent's Name:		E-mail:
If an Employee: Position/Title:		Department/Office & Location
Bargaining Unit:		Work Ext.#:
Respondent's Supervisor:		Supervisor's Position/Title:
If a Student:	FreshmanSophomoreJuniorSeniorGraduate			Major:
Contact Information:
Complaint Allegations
Explain the nature of your complaint: (include WHEN and WHERE it occurred)
Are there any documents in your possession related to the allegations of the complaint?					YesNo
Witness Information
Witness #1 - Name & Contact Information:
Summary:
Witness #2 - Name & Contact Information:
Summary:
Witness #3 - Name & Contact Information:
Summary:
Supplemental Information