Discrimination Complaint Form Discrimination Complaint Form Campus Security/Behavioral Care Team Form Your InformationName First Last A Number PhoneAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Your relationship with the college.Discrimination TypeSelect Discrimination Type (Check all that apply) Race/Color Gender National Origin Disability Sexual Harassment Religion The accused is a: Jefferson State Employee Jefferson State Academic Student Workforce Education Student Adult Education Student Non-Student/Non-Employee Person(s) or entity responsible for the alleged discrimination?Details of EventDate MM slash DD slash YYYY Time : Hours Minutes AM PM CampusJeffersonShelbyPell CityClantonBuilding 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* MM slash DD slash YYYY Δ
