KCCNY Discrimination & Harassment Reporting Form
I am filing this complaint for:
*
Myself
On behalf of someone else
If you are filing on behalf of someone else:
I was present and witnessed the incident/behavior
The individual being harassed told me about the incident, but I was not there
Someone else who witnessed the incident/behavior told me
Your Name
First Name
Last Name
I wish to stay anonymous
Date of most recent incident
*
-
Month
-
Day
Year
Date
On which KCCNY trip or activity did this event occur?
Who is the subject (accused harasser) for this incident?
*
First Name
Last Name
Who witnessed this incident? (Name all those present)
Please describe the nature of your complaint. (Give, in as much detail as possible, a description of the incident/behaviors. If citing multiple instances, include dates, witnesses, locations/trips and any additional information that would be helpful in resolving your complaint. If specific language was used, please use quotes as best as you remember.)
*
What type of discrimination or harassment do you classify this instance as:
Please Select
sex discrimination
race discrimination
ethnic discrimination
national origin discrimination
age discrimination
sexual orientation discrimination
religious discrimination
sexual harassment
bullying or verbally abusive behavior
Was alcohol involved?
No
The complaintant was consuming alcohol
The accused harasser was consuming alcohol
Both parties were consuming alcohol
I do not wish to answer this question
Requested Remedy. (What do you think the final outcome should be?)
Is there anyone on the board or Inclusive Environment Committee (IEC) you do not wish to receive this complaint?
President, Sean Kraft
Vice President, Erik Werner
Becky Doster
Sean Creamer
Andrea Dover
I fully understand the contents of the entire statement made by me. The statement is true and made without threat of coercion. I understand submitting a false complaint could negatively affect my standing with KCCNY.
Submit
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