Anonymous Report of Discrimination - Florida Southern College in Lakeland, FL

*Status of the person experiencing the discrimination

Faculty Staff/Administrator Student Student Employee Applicant Other

I would like to identify myself or receive help from the Office of Accountability, Education and Compliance

Gender of Complainant

Race of Complainant

*Basis of Complaint (check all that apply)

*Accused Perpetrator/Respondent status

*Respondent First Name

*Respondent Last Name

Position/Title

Department

Phone Number

*Gender of Accused Perpetrator / Respondent

Race of Respondent

*Date/Time of Incident

*Location where discrimination occurred

Physical Location Digital Environment

*Statement of discriminatory, harassing, or retaliatory conduct

Harm Suffered

i.e., Termination, Resignation, Suspension, Demotion, Written Reprimand, Lower Class Grade, Dropped the Class, Emotional Distress, Poor Performance Evaluation, etc.)

Is anyone else aware of the incident?

Comparatives - Different Treatment

List of person(s) who were treated more favorably than you under similar circumstances

Comparatives - Similar Treatment

List any person(s) who may have experienced a similar incident from the respondent

Would you like someone from any of these offices to follow up with you?

Student Counseling Center Campus Ministries Campus Safety and Security Student Health Center Academic Center for Excellence