COMPLAINT INFORMATION REPORT
Please complete and return to the Affirmative Action Office, 328 Boucke Building, University Park, PA 16802
Phone: (814) 863-0471 Fax: (814) 863-7799 Email:
Definitions: Please see definitions for Discrimination, Harassment and Retaliation on the last page of this form.
Name of person bringing complaint:Date: / Faculty Staff Student
Department: / Job Title:
Phone (w): / Phone (h):
Supervisor: / Phone:
Type of complaint ____Discrimination ____Harassment ____Retaliation
Basis of complaint:
____Age ____Sexual Orientation
____Race Discrimination ____Marital or Family Status
____Color ____Pregnancy
____National Origin ____Pregnancy-Related Conditions
____Religion ____Physical or Mental Disability
____Creed ____Gender
____Service in the Uniformed Services ____Perceived Gender
(as defined in state and federal law) ____Gender Identity
____Veteran status ____Genetic Information
____Sex ____Political Ideas
(1) Explain what has occurred which leads you to believe you have been subjected to discrimination, harassment and/or retaliation. (Please be specific) (Use additional sheet if necessary.)
______
(2) Where and when did the incident(s) occur? (Please be specific)
______
(3) Who do you feel is responsible for the alleged discrimination, harassment or retaliatory act/behavior? (Please provide names and job titles of all individuals involved)
Name Title
______
(4) Why do you feel the alleged behavior/incident(s) is discriminatory, harassment or retaliation? Explain
______
(5) Please list all witnesses that may have heard or seen the incident(s).
Name Title Phone
______
(6) Please provide the names and job titles of others who were not witnesses, but might be able to support your allegation of discrimination, harassment or retaliation.
Name Title Phone
______
(7) Do you have any documentation or evidence to support your claim of discrimination, harassment or retaliation? ______Yes ______No
(If Yes, please attach a copy to this form)
(8) Have you tried to address the situation by discussing it with your supervisor or others? (If yes, please provide information below.)
Name Date Outcome
______
(9) What outcome are you seeking?
______
(10) Do you wish to proceed with:
Informal resolution______
Formal investigation______
Think further about processing complaint______
______
Signature Date
Definitions:
Discrimination
Conduct of any nature that denies an individual the opportunity to participate in or benefit from a University program or activity, or otherwise adversely affects a term or condition of an individual’s employment, education, or living environment, because of the individual’s age, race, color, ancestry, national origin, religion, creed, service in the uniformed services (as defined in state and federal law), veteran status, sex, sexual orientation, marital or family status, pregnancy, pregnancy related-conditions, physical or mental disability, gender, perceived gender, gender identity, genetic information or political ideas.
Harassment
A form of discrimination consisting of physical or verbal conduct that substantially interferes with an individual’s employment, education or access to University programs, activities or opportunities. Harassment may include, but is not limited to, verbal or physical attacks, graphic or written statements, threats, or slurs. Whether the alleged conduct constitute prohibited harassment depends on the totality of the particular circumstances, including the nature, frequency and duration of the conduct in question, the location and context in which it occurs and the status of the individuals involved.
Retaliation
Adverse action taken by a member of the University faculty, staff, or student body against any individual on the basis of a good faith report made by such individual, or on the basis of such individual’s participation in an investigation, hearing, or inquiry by the University or an appropriate authority, or participation in a court proceeding relating to suspected wrongful conduct at the University. Retaliation shall include, but not limited to, harassment, discrimination, treats of physical harm, job termination, punitive work schedule or research assignments, decrease in pay or responsibilities, or negative impact on academic progress.
AAO/cbb/revised/11/15