Name:

Today's Date:

Address where you can be reached:

Phone where you can be reached:

Email where you can be reached:

Please Check One:

Faculty   Academic Staff    Classified   Student   Other

Please indicate the nature of your complaint (check all those that apply):

Race  

National Origin  

Age

Marital Status  

Creed or Religion

Disability  

Sexual Orientation

Parental Status  

Sex / Gender  

Ancestry  

Pregnancy  

Other

Date on which the alleged complaint occurred:

Short Summary of alleged complaint:

Have you filed a complaint with any other agency or department? 

Yes No

If yes,

With whom?

Please note that all of your inquiries, concerns and questions will be kept in confidence.