Equal Opportunity Complaint Form General Information I am an Evergreen Student Faculty Staff Other Name * Today's date Year Year20162017201820192020 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Phone Number * Email * Complaint Details Alleged Offender's (Respondent) Name * This is a complaint of: * Discrimination Sexual Harassment Other 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): Employees Only Have you notified your supervisor? * Yes No Supervisor's Name Outcome/Actions Taken Have you filed a complaint with any other agency? * Yes No Agency SignatureBy submitting this form I affirm all information is accurate and true to the best of my knowledge. This complaint is made in good faith.
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