CCAC C IVIL R IGHTS V IOLATION C OMPLAINT F ORM If you believe that you have been the victim of discrimination and/or harassment based on a protected classification, such as race/ethnicity, gender/sex, age, and or disability status, you may file a formal complaint by completing this complaint form. The College may be obligated to investigate even without your formal, written complaint. Date of Complaint: Name (Complainant): ID#
Contact Information: Check One: Employee
Student
3 rd Party Vendor
Guest/Visitor
If you are not the victim, please include their name(s) Is victim an employee, student, authorized volunteer, or guest/visitor? Check One: Employee Student 3 rd Party Vendor
Guest/Visitor
Name(s) of who you believe committed the alleged act(s) (Respondent): _____________________________________________________________________________ Is person an employee, student, authorized volunteer, or guest/visitor? Check One: Employee Student 3 rd Party Vendor Guest/Visitor Please describe the alleged incident(s), and when and where it occurred. Also, please attach any supporting documentation and evidence. If more space is necessary, please continue your comments on the back of this form, or on a separate sheet of paper. _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
Appendix A
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