Complaint Form: Discrimination, Harassment, and Retaliation

Instructions
This form provides preliminary information to the Office for Institutional Equity & Diversity to assist in resolving violations of NC State University’s Equal Opportunity and Non-Discrimination Policy. Please complete the form to the best of your knowledge. The information you provide will be kept confidential to the extent permitted by law. If you have questions, please contact Amy Circosta, Assistant Vice Provost for Equal Opportunity, at 919-513-1234 or at amy_circosta@ncsu.edu. NOTE: If you wish to submit your complaint anonymously, you may omit Contact Information, print this form instead of submitting it online, and deliver or send it to: Amy Circosta, Assistant Vice Provost for Equal Opportunity Office for Institutional Equity & Diversity 220 Winslow Hall NC State University Box 7530 Raleigh, NC 27695-7530 Fax: 919-513-1428 Note: An asterisk () indicates a required field.*
Contact Information
Last Name:
First Name:
Address:
City:
State:
Zip:
Home Phone:
Mobile Phone:
Work Phone:
Email:
Prefer contact by:	Home phone Mobile phone Work phone Email Other: (Please list.)
Department or Major (if student):
Administrative Unit/Division/College:
Classification:	EPA Faculty EPA Non-Faculty SPA Temporary Undergraduate Student Graduate Student Other: (Please describe.)
Sex (optional):	Female Male Transgender
Date of Birth (optional, please enter in MM/DD/YYYY format):
Race (optional):
National Origin (optional):
Complaint Information
Please provide the following information about the individual(s) you believe discriminated against, harassed, or retaliated against you. If you do not have all of the information, you may leave fields blank.
Last Name:
First Name:
Address:
City:
State:
Zip:
Phone:
Email:
Department or Major (if student):
Administrative Unit/Division/College:
Classification:	EPA Faculty EPA Non-Faculty SPA Temporary Undergraduate Student Graduate Student Other: (Please describe.)
Most recent date of alleged discriminatory, harassing, or retaliatory action toward you (Please enter in MM/DD/YYYY format.): *
When did the alleged discriminatory action(s) start? (Please enter in MM/DD/YYYY format.) *
Do you feel this happened to you because of: *	Age(40 & over) Color Creed Disability Gender Identity Gender Expression Genetic Information National Origin Pregnancy Race Religion Retaliation Sex Sexual Orientation Veteran Status Other: (Please describe.)
In your own words, briefly describe what happened to you that you believe was discriminatory, harassing, or retaliatory. Please begin with the most recent incident and explain how the behavior or action relates to the category or categories checked above. *
Please select one: *	I intend to file a complaint under the Resolution Procedures for Discrimination, Harassment, and Retaliation Complaints with this form. (What does this mean?) I do not intend to file a complaint under the Resolution Procedures for Discrimination, Harassment, and Retaliation Complaints with this form. (What does this mean?)
Submit Your Complaint
By submitting this form, I agree that: I was provided a copy of NC State's Equal Opportunity and Non-Discrimination Policy and Resolution Procedures for Discrimination, Harassment, and Retaliation Complaints. I understand that by informing OIED of my concerns, OIED may be obligated to take measures necessary to address potential violations of the Equal Opportunity and Non-Discrimination Policy. I agree to keep this matter confidential to the extent permitted by law.
Updated on 5/31/11 by EMS

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Complaint Form: Discrimination, Harassment, and Retaliation