Discrimination Complaint Form - Jefferson State Community College

Your Information

Name

First Last

A Number

Phone

Address

Street Address Address Line 2 City State ZIP Code

Email

Your relationship with the college.

Select Discrimination Type (Check all that apply)

The accused is a:

Person(s) or entity responsible for the alleged discrimination?

Date

Time

:

Campus

Building

Room

How were you treated differently from other peers? (Describe - Who, What, When, Where, How, and Why)

How would you like the situation resolved?

Sign name as signature.*

Date*