Discrimination Anonymous Report Form - 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:

Basis of Complaint (check all that apply):

Race
Disability
Retaliation
National Origin
Veteran Status
Age
Color
Religion
Genetic Information
Pregnancy
Marital Status
Other

Accused Perpetrator/Respondent status:

Faculty
Staff/Administrator
Student
Student Employee
Applicant
Other

Respondent First Name:

Respondent Last Name:

Gender of Accused Perpetrator / Respondent:

Female
Male
Trans Identifying
Gender Queer - Gender Non-Conforming
Different Identity
Prefer Not to Answer

Race of Respondent:

Hispanic or Latino
White
Black or African American
Native Hawaiian or Pacific Islander
Asian
Two or More Races

Date/Time of Incident:

Location where discrimination occurred:

Statement of discriminatory, harassing, or retaliatory conduct:

Please describe in detail the incident(s) you consider to be discriminatory, harassing, or retaliatory. Please provide the first and last names of all individuals involved for each incident.

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?:

Yes
No

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