Full Name
Phone
Email
Address
City
State
Postal code
Type of Complaint
*
Discrimination
Harrassment
Retaliation
No elements found. Consider changing the search query.
List is empty.
Date of Incident
*
Time of Incident
Location of Incident
*
Canton Campus
Havana Center
Macomb Campus
Rushville Center
Other
No elements found. Consider changing the search query.
List is empty.
Other Location
Identify involved people (Specify name, gender, role-- ie: victim, witness, alleged--contact information
If this is a discrimination or harassment complaint, please indicate the protected status(es) that is/are the basis of the alleged behavior:
Race/Ethnicity
Marital Status
Religion
Nationality
Sexual Orientation
Veteran Status
Sex/Gender
Genetic Predisposition
Disability
Age
Describe the incident(s)/event(s) including date, times, locations, and any potential witnesses to the behavior. Please be specific to identify the people in the incident and their roles (faculty, staff, student, campus visitor):
*
Describe the impact the behavior has had on you:
*
Have you taken any action to stop the behavior?
*
Yes
No
If you have taken action to stop the behavior, what actions have you taken and what was the outcome?
Please add any additional information that supports your complaint:
What remedy are you seeking?
*
Supporting documentation attachment 1:
Supporting documentation attachment 2:
Supporting documentation attachment 3:
Captcha
Submit