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Equity & Civil Rights Compliance
Initial Intake Form
This form will provide Preliminary Information in order to assist in the Initial Review of your Complaint. This form is to be completed prior to filing a Formal Complaint with Equity & Civil Rights Compliance Investigations & Hiring.
Name
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Phone
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Department/Unit
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How would you like to be addressed during this Investigative Process (i.e., Mr. Smith, Ms. Smith, John, Jane, etc.
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Please also share your preferred pronouns (i.e., ‘she-her-hers’ or ‘they-them-theirs’) so that we can use appropriate references in any future communications with you
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Gender
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Male
Female
Race
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American Indian or Alaskan Native (Not Hispanic or Latino)
Asian (Not Hispanic or Latino)
Black or African American (Not Hispanic or Latino)
Hispanic or Latino
Multiracial/Two or More Races (Not Hispanic or Latino)
Native Hawaiian or Pacific Islander (Not Hispanic or Latino)
White (Not Hispanic or Latino)
Please select your current status
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Faculty
Staff
Student
Applicant
Other - If other, please specify.
If other, please specify
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E-mail
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College/Division
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Address
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City
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State / Province / Region
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ZIP / Postal Code
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Country
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Please answer the following questions
If faculty/staff, please state your immediate supervisor’s Full Name. (If not faculty/staff, enter “N/A” in the next three boxes)
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Supervisor’s Position Title and Department
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Supervisor’s Telephone Number
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If student/other, please state the Full Name of the Dean of the College or Department Chair of the Department where the incident you believe was discriminatory took place. (If not a student, enter “N/A” in the next two boxes.)
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Dean or Department Chair’s Telephone Number
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I believe I was discriminated against by the following
Faculty
Staff
Student
Applicant
Other - If other, please specify.
Full Name of Person you believe discriminated against you
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Position Title and Department
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Most recent date of action you believe was discriminatory
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Type of Unlawful Action (Check all that apply). If you previously participated in EEO activity (complained about discrimination, participated in someone else’s complaint, or requested a reasonable accommodation), and an adverse action was threatened or taken thereafter, you should check the box next to Retaliation
Discrimination
Discrimination
No
Discrimination
Yes
Harassment
Harassment
No
Harassment
Yes
Sexual Misconduct
Sexual Misconduct
No
Sexual Misconduct
Yes
Retaliation
Retaliation
No
Retaliation
Yes
Please specify the month/year of the prior EEO activity
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Discriminatory Basis: You believe the incident(s) at issue occurred because of (Check all that apply)
Race
Race
No
Race
Yes
Sex
Sex
No
Sex
Yes
(Please specify if your sex discrimination complaint is regarding one of the following: gender, transgender status, pregnancy or sexual orientation)
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Age (over 40)
Age (over 40)
No
Age (over 40)
Yes
National Origin
National Origin
No
National Origin
Yes
Please specify your national origin
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Veterans Status
Veterans Status
No
Veterans Status
Yes
Disability
Disability
No
Disability
Yes
Please specify whether the medical condition is Mental or Physical
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Genetic Information
Genetic Information
No
Genetic Information
Yes
Color
Color
No
Color
Yes
Please specify
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Creed
Creed
No
Creed
Yes
Religion
Religion
No
Religion
Yes
Please specify
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Other (Please Specify)
Other (Please Specify)
No
Other (Please Specify)
Yes
Please give a brief description of the incident(s) you believe was/were discriminatory. Please include the date(s) for each incident.
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What resolution are you seeking for the incident(s) currently at issue?
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Have you previously reported or otherwise complained about the incident(s) described above or related acts of discrimination, harassment, retaliation, or sexual misconduct to a University supervisor or official? If so, please identify (i) the individual to whom you made the report, (ii)the date you made the report, and (iii) the resolution.
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This is an internal process.
I affirm that I have read the above information and it is true to the best of my knowledge and belief.
First and Last Name (This will serve as your electronic signature)
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Date
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