Fair Practices Complaint Intake Form

SU Fair Practices Complaint Number
A Maryland University of National Distinction
INTERNAL FAIR PRACTICES COMPLAINT INTAKE FORM
This compliant form is to be utilized for reporting conduct that is believed to be in violation of Salisbury University’s Fair
Practices policies.
1. COMPLAINANT – Person who alleges the violation of Fair
Practices policies:
RESPONDENT – Person you believe to be responsible for the
alleged violation of Fair Practices policies:
Last Name
Last Name
First Name
First Name
Primary Role
on Campus:
Faculty
Student
Third Party
Staff
Other, please state:
Primary Role
on Campus:
Position / Title
Position / Title
School / Dept.
School / Dept.
Home Address
Home Address
City
State
Zip Code
Faculty
Student
Staff
Other, please state:
City
Phone Number
Phone Number
Email
Email
State
Third Party
Zip Code
2. BASIS OF YOUR COMPLAINT: What is the reason for your claim of discrimination? (Please check all applicable items.)
Age
Ancestry
Color
Disability
Gender Expression
Gender Identity
Genetic Information
Harassment
Marital Status
National Origin
Political Affiliation
Pregnancy
Race/Ethnicity
Religion
Reprisal/Retaliation
Sex
Sexual Harassment
Sexual Misconduct
Sexual Orientation
Veteran Status
Other, please state:
Title IX
If you checked color, religion or national origin, please specify:
If you checked genetic information, how did the Respondent obtain the genetic information:
What type of genetic information is involved:
genetic testing
family medical history
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genetic services
3. ADVERSE ACTION AGAINST YOU: Indicate action(s) you believe the Respondent(s) took or failed to take because of age, ancestry,
color, disability, gender expression/identity, genetic information, marital status, national origin, political affiliation, pregnancy,
race/ethnicity, religion, sex, sexual harassment/misconduct/orientation, Title IX, veteran status, or other protected category.
(Please check all applicable items.)
Academic Grievance
Access to Program/Activity
Accommodation to Disability
Award
Bullying
Demotion
Evaluation
Exclusion from Program /Activity
Grade Assignment
Harassment
Hazing
Hiring
Intimidation
Job Assignment
Job Benefits
Layoff
Pregnancy Leave
Promotion
Recall
Religious Observance
Segregated Facilities
Seniority
Suspension
Termination
Testing
Training
Wages
Working Conditions
Other, please state:
4. INFORMATION ABOUT THE INCIDENT(S): Provide general information about your allegations.
Date conduct occurred: (Please provide the date of the last alleged act of discrimination.)
Number of Incidents:
Name of Supervisor or Manager aware of your allegations:
Witness 1 : Name
Title/Role/Department:
Witness 2: Name
Title/Role/Department:
Witness 3 : Name
Title/Role/Department:
Witness 4: Name
Title/Role/Department:
Witness 5 : Name
Title/Role/Department:
5. NATURE OF THE COMPLAINT: Explain as briefly and clearly as you can what happened and how you believe you were
discriminated/retaliated against. Please be sure to include the following, at a minimum:
• Why you believe you were discriminated/retaliated against;
• What harm, if any, was caused to you or others as a result of the alleged discriminatory act(s);
• Dates, places, names and titles or persons involved and witnesses, if any;
• How you believe other persons were treated differently from you;
• What explanation, if any, was offered for the act(s) by the Respondent(s);
• Attach any written documentation pertaining to this matter.
If this complaint is based on disability, please describe the disability, your history of disability, or why you think you were/are
regarded as disabled.
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I believe that I have been subjected to a discriminatory practice because (if necessary, attach additional sheets):
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6. RELIEF SOUGHT: What remedy(ies) do you seek to resolve this complaint to your satisfaction? (i.e., stop inappropriate behavior
reinstatement of job or status in academic program, removal of discipline, change or removal of academic record or grade, etc.)
7. SIGNATURE AND VERIFICATION: I affirm that, to the best of my knowledge or belief, the information contain herein is true and
factual. Additionally, I understand that the effective date of filing this compliant is the date this form is physically received by the
Fair Practices Office. I further understand that any person who knowingly provides frivolous, false or fraudulent information in a
Fair Practices complaint may be subject to discipline. If applicable, I hereby authorize the release of any medical information
needed for the investigation.
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Signature of Complainant:
Date:
FAIR PRACTICES OFFICE USE ONLY:
Received by:
List all attachments received with form:
Signature:
Received date:
Respondent(s) notification date:
Investigative Report/Decision date:
Was Report/Decision Appealed?
Yes
No
Appeal date:
Final Decision Date:
Complaint Filed with External Agency?
Agency’s Name:
Yes
No
Date:
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