UTC Equity and Inclusion Complaint Form | University of Tennessee at Chattanooga

Name of Complainant:

Address:

Phone Number:

Alternate Phone number:

Email:

	Status of Complainant:
Faculty	Faculty
Staff	Staff
Student	Student
Other	Other

If Complainant is an employee:

Department:

Position Title:

Supervisor:

If Complainant is a student:

Student Status:

Graduate

Undergraduate

	Type of Complaint:
Discrimination	Discrimination
Harassment	Harassment

	Basis of Complaint:
Age	Age
Color	Color
Disability	Disability
Gender Identity	Gender Identity
Marital Status	Marital Status
Military Service	Military Service
National Origin	National Origin
Parental Status	Parental Status
Pregnancy	Pregnancy
Race	Race
Religion	Religion
Retaliation	Retaliation
Sex/Gender	Sex/Gender
Sexual Assault	Sexual Assault
Sexual Harassment	Sexual Harassment
Sexual Orientation	Sexual Orientation
Sexual Violence	Sexual Violence
Veteran Status	Veteran Status

Name of Respondent(s):

Department:

Title:

	Status of Respondent(s):
Faculty	Faculty
Staff	Staff
Student	Student
Other	Other

	Relationship of Respondent(s) to Complainant:
Co-Worker	Co-Worker
Client/Customer	Client/Customer
Faculty	Faculty
Subordinate	Subordinate
Supervisor	Supervisor
Student	Student
Other	Other

Describe specific act(s) alleged with date(s), time(s) and location(s), if possible, and the names and contact information of any witnesses who may have observed the incident or behavior and/or experienced similar treatment.

Did you take any action to stop the alleged behavior?

Yes

If yes, please summarize the action taken:

How would you like to see the situation resolved and/or what remedy are you seeking?

Additional information or comments:

I am aware that an informal process is available to resolve the complaint, and feel that a formal complaint is appropriate to resolve the discrimination and harassment I allege in this complaint. I understand that I may have rights to relief under state and federal laws, and that complaints of discrimination may be filed with state and federal civil rights agencies.

I certify that to the best of my knowledge, the information that I provided is accurate and the events and circumstances are as I have described them. I understand that a copy of this complaint will be provided to the respondent. I agree to cooperate with any investigation conducted by the University into this matter and provide whatever evidence the University deems relevant. While complete confidentiality cannot be guaranteed, I understand that all complaints will be handled in such a way that confidentiality will be protected to the fullest extent possible.

I understand that if I am found to have knowingly misstated any material fact in this complaint I may be subject to discipline in accordance with applicable University policies and procedures for students and employees.

Signature:

Date:

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