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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 Last Name:

**Your position/title:

**Your phone number:

**Your email address:

**Date of incident: (MM/DD/YYYY Click or tap to enter a date.)

**Location of incident:


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:

Your affiliation with Metropolitan Community College is:

Type of discrimination you are reporting (please check all that apply):

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)
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.).
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):