Discrimination/Harassment Complaint Form

Completion of this form is not required to formally initiate a complaint; however, completing this form will assist in the investigatory process. When completed, please return this form to the Director of Human Resources, Room 107, Walter Washington Administration/Classroom Building (WWACB). You will be contacted as soon as possible for a confidential interview.

 

The information you provide below is considered sensitive and will be shared only with those who are considered essential to the investigation and disposition of this complaint. 

 

Today's Date   
Name   
Position   
Department   
Phone Number   
Immediate Supervisor   
Describe the alleged discriminatory/harassment incident(s).    
Who was responsible for the alleged discriminatory/harassment incident(s)?    
Identify any witnesses to the alleged discrimination/harassment incident(s)?    
Where did the alleged discrimination/harassment incident(s) take place?    
List the date(s) and time(s) that the alleged discrimination/harassment incident(s) occurred.    
Have you reported this incident to anyone else? If so, whom?    

 

Alcorn State University is an equal opportunity employer. It is the University's policy that all employees have a right to work in an environment free of discrimination and harassment based on sex, age, race, color, national origin, religion, disability, or any other basis protected by federal, state, or local law.

Alcorn State University's policy prohibits retaliation against any employee for complaining about discrimination or harassment. 

 

 

 

  

 
 
1000 ASU DRIVE   |   ALCORN STATE MISSISSIPPI 39096-7500   |   PHONE: 601.877.6100