Discrimination Complaint (Procedure 2.1800 Form)

Discrimination Report Form

(If you use the back of these pages or additional paper, please be sure to number your responses.)

Name: __________________________________________________________________

Position: __________________________________________ Office #: ____________

Hours on campus:___________________________ Extension #: __________________

Person receiving this complaint: ____________________________________________

Date of receipt of complaint: _______________________________________________

1. Date(s) of alleged incident(s) of discrimination:

_________________________________________________________________

2. Name and position of person(s) who you feel has discriminated against you:

__________________________________________________________________

3. Description of facts and circumstances surrounding alleged incident(s) of discrimination:

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

4. When, where and how often has the alleged discriminatory action taken place?:

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

5. What has been your response to the alleged discriminatory action(s)?:

_________________________________________________________________

_________________________________________________________________

6. What would you suggest as a resolution of your complaint?:

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

__________________________________________________________________

7. Names of persons who might have knowledge of the facts surrounding this complaint:

_________________________________________________________________

__________________________________________________________________

__________________________________________________________________

____________________________________________________________
Complainant Signature / Date

2.1800 Attachment 2

EQUITY COORDINATOR REPORT ON DISCRIMINATION COMPLAINT

Date: ________________________________________

To: __________________________________________, President

From: ________________________________________, Equity Coordinator

(Copies to complainant and respondent)

Name of Complainant: ____________________________________________________

Name of Respondent: _____________________________________________________

Having conferred with the complainant, the alleged discriminating person, and other appropriate persons, about an incident which occurred on or about _________________, 2000, I find the following:

1. Basis of complaint: _________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

2. Issues/facts not in dispute:

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

3. Issues/facts in dispute:

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

4. Resolution/recommendation/disposition of inquiry:

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

2.1800 Attachment 3

HEARING REQUEST

Name: ___________________________________ Soc. Sec. No.:_________________

Position: ____________________________________ Office #: __________________

Hours on campus:___________________________ Extension #: _________________

Person receiving this request: _______________________________________________

Date of receipt of this request: _______________________________________________

During the past few weeks, there has been an attempt to resolve a complaint of alleged discrimination through an inquiry. However, I request a hearing for the following reasons:

________________________________________________________________________

________________________________________________________________________

_______________________________________________________________________

________________________________________________________________________

I do not believe that an inquiry would bring a satisfactory resolution to this complaint for the following reasons:

________________________________________________________________________

________________________________________________________________________

_______________________________________________________________________

________________________________________________________________________

Therefore, I request that a panel be convened, as provided in the discrimination complaint procedure, for a hearing on this complaint.

I have read and understand the procedure and time constraints for the hearing phase in the College's discrimination procedure and have been provided a written copy of the same.

_______________________________________________________________
Complainant Signature / Date

2.1800 Attachment 4

PRESIDENT'S RESPONSE TO REPORT ON DISCRIMINATION COMPLAINT

(Copy of this form is to be distributed to: complainant, respondent, supervisor of complainant, supervisor of respondent, Equity Coordinator, Director of Human Resources and others as required)

Date: ______________________________________________________

To: _______________________________________________________

From: _____________________________________________________, President

Having reviewed the findings of the Equity Coordinator and/or hearing panel, submitted to me on __________________, 2000, I have:

______ Accepted the findings and/or recommendations as submitted.

______ Accepted the findings and/or recommendations with the following modifications:

______ Rejected the findings and/or recommendations and made the following findings and/or recommendations:

In accordance with my acceptance/acceptance with modification/rejection, I direct that the following action be taken:

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