Discrimination Complaint Form

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Discrimination Complaint Form

The purpose of this form is to record information required to initiate an investigation into an alleged violation of the College’s Policy on Affirmative Action (PAA). All reasonable efforts will be made to maintain the confidentiality of the parties involved during the complaint procedure in accordance with the PAA.

If you believe you have been subjected to any prohibited conduct, you may submit this form to register a complaint or contact Emmanuel Echevarria, Title IX Coordinator and the Affirmative Action Officer. To reach Mr. Echevarria, please call 774-357-2333 or write to diversitytitleix@bristolcc.edu

Retaliation against a student, employee or any other person in the College for filing a complaint or for cooperating in an investigation of a complaint is strictly prohibited. All parties to a complaint may have an advisor (for union employees this may be a union representative) assist them throughout the process.

Date Filed:

Date(s) of Alleged Discrimination:

A. Name:

B. Check One:

Student

Employee

Other:

Program/Department:

C. Type of Prohibited Conduct (please check applicable category(ies):

Discrimination

Retaliation

Discrimination Harassment

Sex-Based Harassment

D. Type of alleged discrimination or harassment (please check applicable category(ies)):

Other:

*Please see the PAA for definitions of above terms.

E: Name of individual(s) you believe discriminated against you:

F: List any witnesses:

G. Description of Complaint - please list the sequence of events, including dates, if possible, and any relevant facts and statements to support your complaint

of discrimination:

If additional writing space is needed, please attach additional documents here:

To the best of my knowledge and belief, the above information is complete, true and accurate and not a “false complaint” as defined under this Policy. I hereby submit this complaint under the College’s Complaint Procedure.

Signature of Complainant:

Date:

Check one that applies to you:

Student

Employee

Email Address:

Department/Area

Phone Number:

Other*

If you selected Other, please specify here:

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