Equal Opportunity Complaint Form General Information I am an Evergreen: Student Faculty Staff Contractor Other Name: Today's date Email Complaint Details This is a complaint of: Discrimination Harassment Discrimination on the basis of: - None -RaceColorReligionCreedNational OriginSexSexual OrientationGender IdentityGender ExpressionGenetic InformationMarital Status AgeDisabilityPregnancyStatus as a Disable VeteranStatus as a Vietnam Era VeteranStatus as other Covered Veteran Harassment on the basis of: - None -RaceColorReligionCreedNational OriginSexSexual OrientationGender IdentityGender ExpressionGenetic InformationMarital Status AgeDisabilityPregnancyStatus as a Disable VeteranStatus as a Vietnam Era VeteranStatus as other Covered Veteran Alleged Offender's (Respondent) Name/Title: Please describe the specific incident(s) WHAT happened: WHEN (including dates and times for each incident): WHERE (locations for each incident): Witnesses (include contact information): NOTE: If reporting sex or gender-based harassment or misconduct, please also review the other reporting options available to you at: www.evergreen.edu/titleix/options Certification Signature I affirm all information is accurate and true to the best of my knowledge. This complaint is made in good faith.
