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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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 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
