Discrimination/harassment Complaint Form
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1
2
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4
5S
. C
T
C
T
LOUD
ECHNICAL AND COMMUNITY
OLLEGE
D
/H
ISCRIMINATION
ARASSMENT
C
F
OMPLAINT
ORM
Date:
Name of COMPLAINANT:
(If more than one complainant, complete intake form for each)
Address (local):
Address (residence):
City:
State:
Zip:
Sex:
Male
Female
Phone: [work] ____________________
[home] ____________________
Status:
Student
Faculty
Staff
Administrator
External/Non-Campus
T
:
D
R
YPE OF COMPLAINT
ISCRIMINATION
HARASSMENT
ETALIATION
I
/
/
:
WAS DISCRIMINATED
HARASSED
RETALIATED AGAINST ON THE BASIS OF MY
Race
Age
Reliance on Public Assistance
Sex
National Origin
Sexual Orientation
Color
Physical Disability
Veteran’s Status
Creed
Mental Disability
Membership/Activity in Local
Religion
Marital Status
Commission
To report instances of discrimination or harassment submit this completed form to one of these
designated officers:
Nondiscrimination Coordinator: Students
Nondiscrimination Coordinator: Employees
Missy Majerus
Deb Holstad
Title IX Coordinator
Human Resources Director
Office: 1-401
Office: 1-403C
mmajerus@sctcc.edu
dholstad@sctcc.edu
Phone: (320) 308-5922
Phone: 320-308-3227
or (800) 222-1009
or (800) 222-1009
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Parent category: Legal