Complaint of Harassment/Discrimination

PLEASE READ BEFORE COMPLETION OF FORM

Any complaint of harassment/discrimination is considered confidential data under Minnesota Statute 13.39, Subd. 1 and 2. This information is being collected for the purpose of determining whether harassment/discrimination has occurred. You are not legally required to provide this information, but without it, an investigation cannot be conducted. This information may only be released to the Affirmative Action Officer designee, the complainant, the respondent, and appropriate personnel.

1 > 2 > 3
Complainant
Your Role in This Incident *

Your Role in This Incident I was subjected to harassment/discrimination I was witness to harassment/discrimination
Person Subjected to Harrassment/Discrimination Person Subjected to Harrassment/Discrimination * First Last
Witness Name Witness Name * First Last
Your Phone Your Phone * - ### - ### ####
Your Email Address *
Your Classification *
Your Address Your Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
The Complaint
Basis of Complaint (Check all that apply) *

Basis of Complaint (Check all that apply) Race Sex Age Color Creed Religion Disability Marital Status Sexual Orientation Status with Regard to Public Assistance Membership or Activity in a Local Human Rights Commission
Date most recent act of harassment/discrimination took place: Date most recent act of harassment/discrimination took place: * / MM / DD YYYY
If you filed this complaint with another agency, give the name of that agency:
Please describe how you believe you have been harassed/discriminated against (names, date, places, etc.). *
Save my progress and resume later
Enter Your Email Address *

A special link to resume the form will be sent to your email address.

Complaint of Harassment/Discrimination

Complaint of Harassment/Discrimination

Complainant

The Complaint