Discrimination and Harassment Complaint Form

Information

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.

Personal Information

Today's Date (mm/dd/yyyy) *

Full 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.

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