Indian River State College Harassment/Discrimination Complaint Form [PDF]

Please refer to IRSC’s Non-Discrimination and Non-Harassment Policy Violation Reporting Procedures AP-3.131 for more information related to the complaint process.

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Complaint Information

Today’s Date:

Name:

Mailing Address:

Phone Number:

Email:

Status (Check one)

IRSC Employee

IRSC Student

IRSC Applicant

Other (please specify):

Grounds for Complaint

Indicate the ground(s) on which you are making your complaint of harassment/discrimination

Protected grounds for harassment and discrimination complaints
Ground	Ground	Ground
Race	Color	Religion
Marital Status	Gender	Disability
Age	National Origin	Veteran Status
Genetic Information	Ethnicity	Sex
Sexual Orientation	Pregnancy	Sexual Misconduct (Sexual Assault, Sexual Battery and Other Crimes of violence)
Other
Retaliation

Complaint Details

How you would like the complaint to be resolved

Describe how you would like the complaint to be resolved. Be as specific as possible.

Resolution:

Nature of complaint

Please describe the nature of your complaint in detail. If needed, attach an additional page.

Complaint Description:

Witnesses

Identify others who may have observed or witnessed the incident(s) that you described.

Witnesses:

Certification and Signature

I certify that the above (and any of my attached statements) are true and correct.

Your Signature:

For Office Use Only

Date Received:

Received by: