Content

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
Prefer contact by:



Classification:





Sex (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.
Classification:





* 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
Retailiation
Sex
Sexual Orientation
Veteran Status
Other


* Please select one:
Submit Your Complaint

By submitting this form, I agree that:

Updated on 5/31/11 by EMS