Discrimination Form
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
ID Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of faculty/staff member(s) against whom complaint is lodged:
Nature of the complaint:
Facts (What evidence supports the complaint? How may this be verified?)
Have you met with the staff or faculty member regarding this complaint?
Yes
No
If so, when did you meet?
-
Month
-
Day
Year
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What was the outcome of that meeting?
Have you met with the staff member’s supervisor or chair of the academic department?
Yes
No
If so, when did you meet?
-
Month
-
Day
Year
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What was the outcome of that meeting?
Remedy (What solution, if any, do you seek?)
Witnesses (If Any)
Submit
Should be Empty: