Harassment, Discrimination and Violence Complaint Form
This document is confidential and shall only be read by the members of the Investigative Committee. We hope we can find a way to address this issue in a way that empowers and protects you, and our community. ASFA also acknowledges that the following policy is constantly iterating which includes the flow of this complaint form. We welcome all feedback from the community regarding this process, and thank you deeply for your patience.
The policy against Harassment, Discrimination and Violence can be found here.
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Name
First Name
Last Name
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Does your complaint involve a member of the Investigative Committee? * If yes, please mention it in the title of your complaint, so we can take special measures to protect the confidentiality of your complaint
Yes
No
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Nature of Discrimination, Harassment or Violence Describe the incidents as clearly as possible (dates, location, verbal statements, witnesses, etc.) Please use additional pages if necessary.
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Please check any and all that apply:
Was the Discrimination, Harassment or Violence specifically:
Racialized
Sexualized
Gendered
and/or Based on
Transmisia *Transmisia refers to a strong dislike for trans people and gender diversity. More broadly, it is the systemized discrimination or antagonism/opposition of transgender/nonbinary/genderqueer/agender persons. It is commonly referred to as transphobia.
Homomisia *Homomisia refers to a strong dislike of homosexuals and homosexuality. More broadly, it is the systematic oppression, discrimination, or exclusion of same sex individuals. It is commonly referred to as homophobia.
Ableism
Racism
Other (please specify):
Other (please specify):
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Date that Harassment first occurred:
Date that Harassment last occurred:
Is this a recurrent problem?
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Complainant
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Representative
A representative is any person of the complainant's choice who act as their advisor and person of support. The information regarding this person is required if the complainant is anonymous.
Name of your representative to contact you
Email address to contact you
Contact Number (optional)
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Respondent / The person you are reporting (Required)
Name
First Name
Last Name
Respondent’s relationship to the ASFA
Executive of a Member Association
Council Member (Councillor, Chair, Minute keeper)
Executive Member
Volunteer
Employee
A student in the Arts and Science faculty of Concordia University
I do not know
Other (please specify):
Other (please specify):
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What would you like from this process?
Member Associations should be informed of the respondent’s behavior
I would just like the ASFA to be aware that this person has engaged in this problematic behavior for reference in possiblefuture cases
I’d like this person to take mandatory sensitivity training
Other (please specify):
Other (please specify):
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Optional:
Witness contact information:
Evidence (optional): it may be helpful for the investigation process to include screenshots of conversations or other documentation.
Evidence (optional): it may be helpful for the investigation process to include screenshots of conversations or other documentation.
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Do we have permission to use any of this information (except your name, which we will not disclose) to present our recommendations in a closed session of ASFA Council? It should be noted that this is mandatory in order to enforce disciplinary measures and that onlythe necessary information will be shared, without specific details. Councilors are also bound by a duty to protect and ensure theconfidentiality of the cases discussed in closed sessions.
Yes
No
Some information may be presented: (please specify):
Some information may be presented: (please specify):
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