Formal Complaint of Racial Discrimination - Florida Southern College in Lakeland, FL

Complainant Type

*First Name

*Last Name

*Email

Phone Number

Address 1

Address 2

City

State

ZIP Code

Gender of Complainant

Race of Complainant

Ethnicity (Hispanic or Non-Hispanic)

College ID Number

Date of Birth

Current Age

Age at Time of Incident

Classification

Major

Residence Hall

Position/Title

Department

Direct Supervisor

Office Phone Number

Office Phone Extension

*Basis of Complaint (check all that apply)

Race National Origin Color Other

*Respondent Name

*Respondent Gender

*Respondent Race

*Respondent Ethnicity (Hispanic or Non-Hispanic)

*Respondent Type

Respondent Employee Position/Title

Respondent Employee Department

Respondent Employee Supervisor

Respondent Employee Phone

*Description of Complaint

Complaint Documentation

Complaint Documentation Attachment 1

Please select a file

Complaint Documentation Attachment 2

Please select a file

Complaint Documentation Attachment 3

Please select a file

Previous Action

Have you brought this matter to the attention of any other person or department at the college or any external agency such as law enforcement or the EEOC? If so, please list the name(s) and department(s) of all other persons with whom you have discussed this matter and when you had the discussion.

Corrective Action Sought

Describe the relief or corrective action you are seeking from the college and/or the respondent.

Witness Names

Witness Phone Numbers

Witness Email Addresses

Yes, I understand

I understand that by submitting this formal complaint, I am knowingly initiating the formal grievance process (i.e. formal investigation) related to the allegations that have been described.

Yes, I understand

I understand that upon receipt of this formal complaint, the Title IX Co-Coordinator may contact me to gather additional information, if necessary.

Yes, I understand

I understand that upon the Title IX Co-Coordinator’s review, the College will dismiss a formal complaint of sexual harassment under Title IX if the alleged conduct:

Would not constitute sexual harassment as defined in the Sexual Misconduct & Sexual Harassment Policy if proven;
Did not occur in the College’s education program or activity; or
Did not occur in the United States.

I also understand that if a formal complaint of sexual harassment under Title IX is dismissed, the Title IX Co-Coordinator will notify the respondent and me of the dismissal. However, the behavior that does not meet the above criteria may still be addressed under different College policies.

*Full Legal Name

By typing my name, I confirm that I am the person making this formal complaint. I also confirm that the information provided in this formal complaint is true to the best of my knowledge.

*Date

*College ID Number