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Complaint Form

 

Formal Complaints of Unlawful or Prohibited Discrimination 

 

Intake Form  

Complainants may use this form to file a complaint of unlawful or prohibited harassment, including sexual harassment.  You may mail, fax, or email the form to the Office of Social Equity (see specific instructions below for sending completed intake form).

 

COMPLAINANT(S): 

Employee ___             Student ___                Service Provider ___          Visitor/Guest ___

 

Name

Address

Phone Number

Email Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Use additional paper if necessary) 

ALLEGED RESPONDENT(S): 

Name

Office Address

Phone Number

Email Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Use additional paper if necessary) 

DETAILED ALLEGATIONS: 

Basis for Complaint: (circle all that apply):  Race, sex/gender, color, age, religion, national origin, ancestry, disability, organizational affiliation, sexual orientation/gender stereotype, marital status, veteran status. 


Description of Events:  Please describe the events that cause you to believe the University’s policy has been violated.  In additional to your description of what happened please also provide information on who was involved, and dates on which the events occurred.

(Use additional paper if necessary) 

 Complainant has discussed this action and requested relief from the alleged violator: 

Yes ___ No ___

 Describe what steps, if any, have been taken for relief:

(Use additional paper if necessary)

 Witnesses:  If there are witnesses who have personal knowledge of or who observed the events that you have described, please complete the following information on the witnesses:

 

Name

Address

Phone Number

Email Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Use additional paper if necessary) 

Requested Remedy:  How would you like this matter resolved? 



ATTESTATION

I, ______________________________________________________ (name or names) believe the above information and facts are true to the best of my knowledge.
 

_______________________________________________              ________________
(Complainant Signature)                                                                     (Date)
 

_______________________________________________        __________________
(Complainant Signature)                                                                     (Date) 

_______________________________________________           _________________
(Complainant Signature)                                                                     (Date)

 Mail to:  Office of Social Equity, Edinboro University, Room 310, 219 Meadville Street, Edinboro PA  16444
Fax to: 814-732-2153
Email to:  equalopportunity@edinboro.edu