DISCRIMINATION/HARASSMENT COMPLAINT FORM

METROPOLITAN COMMUNITY COLLEGE DISCRIMINATION/HARASSMENT COMPLAINT FORM

The purpose of this form is to record information required to initiate an investigation into an alleged violation of the College’s Discrimination Policies

Background Information

**Your First Name: Your First Name is Required!	**Your Last Name: Your Last Name is Required!
**Your position/title: Your Position/Title is Required!	**Your phone number: Your Phone Number is Required!
**Your email address: Your Email is Required!	**Date of incident: (MM/DD/YYYY Click or tap to enter a date.) Date Of Incident is Required!
**Location of incident: Choose Location ATC CAM Do Space EVC FOC Mahoney Sarpy Ctr N Express S Express SOC Other Location of incident is Required!

Involved Party 1 Information

Respondent 1 First Name:	Respondent 1 Last Name:
Respondent 1 Phone Number:	Respondent 1 Email:

Involved Party 2 Information

Respondent 2 First Name:	Respondent 2 Last Name:
Respondent 2 Phone Number:	Respondent 2 Email:

Involved Party 3 Information

Respondent 3 First Name:	Respondent 3 Last Name:
Respondent 3 Phone Number:	Respondent 3 Email:

Involved Party 4 Information

Respondent 4 First Name:	Respondent 4 Last Name:
Respondent 4 Phone Number:	Respondent 4 Email:

Questions

Your affiliation with Metropolitan Community College is: Choose Status Student Faculty Staff Vendor Guest Other Your Affiliation is Required!
Type of discrimination you are reporting (please check all that apply): Gendor Pregnancy Retaliation Disability Sexual Orientation Race/Color Religion/Creed Genetic Information Gender Identity/Expression National Origin Age Military Service Other
Please select at least one discrimination item.
Description of Complaint - list the sequence of events, including dates, if possible, and any relevant facts and statements. Be sure to include specific details such as who, what, where, and when:
By completing and submitting this form, I agree that I have received electronic access to and reviewed the Board Policy and Administrative Procedures G.08.01: Grievance Process for Student Equity Complaints (Other than Title IX Sexual Harassment Complaints)
Yes. Please check Yes to agree!. I agree that I received electronic access to and reviewed the documents identified above. By typing my name below, I certify that all the information entered into this form is true and correct to the best of my knowledge. Please type your name in the box below. (If you are submitting this form anonymously please type "Anonymous.")
Acknowledgement: All information entered into this report is considered private and protected by the Family Education Rights and Privacy Act of 1974 (FERPA). Do not discuss any identifiable information contained in this report with anyone other than school officials with legitimate educational interest in the matter (such as immediate supervisor, campus vice president for student affairs' office, campus police, etc.).
I UnderStand Please check Yes to agree!. the privacy expectations associated with making this report. I understand that this report is considered to be part of the student's education record and the student may seek access to all information entered into this report.

Supporting Documentation

Attach any photos, video, email, and/or other supporting documents. (5GB maximum total size):

Submission

Email me a copy of this report