Office of Compliance, Equal Opportunity and Affirmative Action (EOAA)

INTERNAL COMPLAINT FORM REGARDING UNLAWFUL DISCRIMINATION AND HARASSMENT

FOR UNIVERSITY POLICY REFER TO 5-16

FOR INVESTIGATION PROCEDURES REFER TO 5-16.1

Form Type

INFORMAL - Pre-complaint counseling/guidance/informal resolution/mediationFORMAL - Formal EOAA investigation conducted by Office of EOAA and/or designated AA Facilitator

Complainant's First Name and M.I.:

(Person filing this complaint of discrimination)

Complainant's Last Name:

Banner ID:

Complainant's Status at the University:

Staff/Faculty (Please list job title & Department/College name):

Campus Location:

Building Name and/or Mailing Address:

Phone Number:

Email:

Title VII

Case Origin

DESCRIPTION OF THE ALLEGED DISCRIMINATORY ACT OR BEHAVIOR:
Describe the discriminatory actions, behaviors or events which occurred. Be as precise as possible with regard to the names of the involved participants, names of witnesses, locations, times, and dates.
PLEASE NOTE: a copy of this complaint will be provided to the accused party. Your Banner ID and contact information will be redacted.

How did you react/respond?

Were there any witnesses? If "Yes", please indicate the names of the witnesses:

Did you tell anyone about this? (Supervisor, Dean, Instructor, Student Ombuds, etc.) If "Yes", please indicate whom:

Do you have any physical evidence (i.e. emails, photos, letters, documents, text messages, Facebook/Twitter posts, etc.) of this claim?

Yes (If so, please provide any copies to EOAA) No

Has your employment or student status been affected in any way as a result of this alleged incident and if so, please describe the effect below.

What proposed resolution and/or remedial action are you seeking?

NOTE:

(*) Complaints filed on “gender discrimination ” will be investigated in accordance with university policy 3342-5-16.2.

While the Equal Opportunity and Affirmative Action Office uses its best efforts to protect information you provide from disclosure, such information may be subject to release under the following circumstances: request for public records, in response to charges filed with the Equal Employment Opportunity Commission (EEOC), the Ohio Civil Rights Commission (OCRC), Department of Education (DOE), Office of Civil Rights and other administrative agencies or complaints filed in state or federal court, whether filed by you or others.

The Family Educational Rights and Privacy Act (FERPA) prohibits disclosure of student information in certain situations. If you are a student, your signature below provides the EOAA office with consent to release relevant information provided by you, or relevant information gathered as part of EOAA’s investigation, (including but not limited to personally identifiable information and other educational records) to the accused individual(s) and to any university personnel involved in the investigation or adjudication of this complaint, as deemed necessary by EOAA in order to complete the investigation. Your Banner ID, home address, and home phone number will be redacted from this form if shared with an accused party.

I have read and understand the contents of this document. All statements and responses are accurate to the best of my knowledge and I declare that this complaint has been made in good faith.

Complainant Signature:

Age (40 yrs. old or older)	Color
Disability	Disabled Veteran
Gender (*)	Genetic Information
National Origin or Ancestry	Race
Religion	Retaliation
Sexual Orientation	Vietnam Era Veteran/Military Status