Discrimination/Harassment Complaint Form
Updated: May 20, 2014
Date of Incident
Location of Incident
All complaints concerning Title VI and VII of the Civil Rights Act of 1964 and 1991, Title IX of the Education Amendments of 1972, 20 U.S.C. Section 1681
et seq. (Title IX) and its implementing regulations, 34 C.F.R. Part 106, the Rehabilitation Act of 1973, and the Americans with Disability Act of 1990, or
any other Federal non-discrimination legislation should accompany this form. Complainant should complete and submit this form to one of the following:
• Employment Applicants or Current Employees: Human Resources & Safety Manager
• Prospective or Current Students: Vice President of Student Services
• Americans with Disability Act: Director, Cleveland Early College High School Relations
If witnesses were present, please list their name, address, and phone number (if known)
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Complainant
(one alleging discrimination/harassment)
:
Job Title (if known)
Name Last MI First Student ID (if applicable)
Mailing Address Street/PO Box/Apt # City State Zip
Home phone
Cell phone
Work phone
Check one of the following:
Employment Applicant Current Employee Prospective Student Current Student
Respondent
(one charged with discrimination/harassment)
:
Job Title (if known)
Name Last MI First Student ID (if applicable)
Mailing Address Street/PO Box/Apt # City State Zip
Home phone
Cell phone
Work phone
Check one of the following:
Employment Applicant Current Employee Prospective Student Current Student
Basis of Discrimination/Harassment:
Please check the appropriate box:
Race/Color National Origin Religion Sex Pregnancy Disability Age Veteran Status Other Please specify: ___________________________
The complainant feels she/he experienced:
Discrimination Harassment
Incident Information:
