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Complaint of Discrimination/Harassment - Faculty & Staff

Answer any questions as completely as possible.   If you do not know the answer to the question, please respond by stating “not known.”  If the question is not applicable, please write “N/A.”

Required fields marked with an (*)

1. Personal Information

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 Male
 Female
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 Yes
 No

Provide the name of a person we can contact if we are unable to reach you:

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2. Employment Information

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Current or Last Pay Rate *

Job Title at Time of Alleged Discrimination *

Department or College where you work(ed) *

Name and Title of Immediate Supervisor *

If applicant, date you applied for job *

Job title applied for *

3. Reason or basis for your claim of employment discrimination? *

 Race
 Color
 Age
 National Origin
 Gender
 Sexual Orientation
 Disability
 Pregnancy
 Veteran's Status
 Political Affiliation
 Religion
 Retaliation
 Other
 

4. What happened to you that you believe if discriminatory? Include the date(s) of harm, action(s), and include the names and titles of the individual(s) who you believe disciminated against you

This complaint of discrimination must be filed within the time limits imposed by law, generally within 300 days of the alleged discrimination.

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Describe in detail the action(s) you believe were discriminatory *

 
 
 
 

Describe in detail the action(s) you believe were discriminatory

 
 
 
 

Describe in detail the action(s) you believe were discriminatory

 
 
 
 

Describe in detail the action(s) you believe were discriminatory

 
 
 
 

Describe in detail the action(s) you believe were discriminatory

For additional discriminatory allegations, please submit written submissions to the Office and Diversity and Equity:
Office of Diversity and Equity at Radford University
Preston Hall 231
PO Box 6890
Radford, VA

5. What reason(s) were given to you for the acts you consider discriminatory? By whom? Title? *

6. Name and describe others who were in the same situation as you. Explain any similiar or different treatment. Who was treated worse, who was treated better, and who was treated the same? Provide race, sex, age, national origin, disability, etc. status of comparator if known. Please provide name, job title, department and telephone number. *

*Answer questions 7-9 only if you are claiming discrimination based on disability. If not, skip to question 10.

7. Please check all that apply:

 Yes, I have an actual disability
 I have had an actual disability in the past
 No disability, but the University treats me as if I am disabled

8. If you are alleging discrimination based on your disability, what is the name of your disability? How does your disability affect your daily life or work activities, e.g., what does your disability prevent or limits you from doing, if anything?

9. Did you ask your employer for any assistance or change in working condition because of your disability?

 Yes
 No

Did you need this assistance or change in working condition in order to do your job?

 Yes
 No

If yes, when and to whom did you make the request? Provide the full name of the person.

Please describe in detail the assistance or change in working condition requested.

10. Are there any witnesses to the alleged discriminatory incidents? If yes, please identify them below and indicate what they will say. Please provide name, job title, department and telephone number. *

11. Have you filed a grievance with another college, department or office in these same issues? *

 Yes
 No

12. Please identify the college, department or office that this grievance has been filed and the filing date. *

13. Have you previously filed a complaint of discrimination at Radford University? *

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 No

14. Please state the nature of your previous complaint of discrimination and the filing date. *

15. Have you filed a complaint with the EEOC or another agency? Please provide the name of the agency and the filing date. *

16. Do you have a representative, such as an attorney or another individual? Please list his or her name, organization, address and telephone number. *

I, the undersigned, certify that this document is a complete and accurate statement of my complaint. I further understand that the information provided herein is not confidential and will be reviewed by the University personnel and employees to determine the existence of facts relevant to this complaint.  I further understand that the information provided herein will be disclosed to the responding party and individuals identified herein as well as for routine use purposes at Radford University. 

By signing this document, I consent to the review, processing, investigation, and disclosure of the enclosed information by the Office of Diversity and Equity as stated above.  I will cooperate with the Office of Diversity and Equity's investigation and complaint resolution activities.  I understand that my failure to cooperate with the Office of Diversity and Equity’s investigation may result in the closure of my complaint.  I further verify that I have been provided with a copy of Radford University Discrimination Complaint Procedure.

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Radford University does not discriminate based on the basis of race, color, age, disability, National Origin, gender, sexual orientation, religion, pregnancy, Veteran’s status, political affiliation, or retaliation.