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Complainant Information

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Basis of the Complaint

*Basis of Complaint (check all that apply):













Respondent Information

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Description of Complaint

Please describe in detail the incident(s) you consider to be discriminatory or retaliatory and why you believe this person discriminated or retaliated against you. Also, please provide the date(s) and locations(s) for each incident including first and last names of individuals involved. Explain why you have contact with these individuals (supervisor, co-worker, faculty, customer, etc.).

Do you have any documentation supporting your complaint such as text messages, print screens, or e-mails? If so, please provide copies of the documentation supporting your complaint along with any explanation behind the documentation.

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

Witnesses

Identify the witnesses who will support your allegations.

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