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COMPLAINT FORM FOR
DISCRIMINATION/HARASSMENT
Instructions:
This
com
p
laint form
is for use by individuals who are eligible to file a complaint of Discrimination or
Harassment under PER 1.10 – Discriminatory Harassment and the Sexual Harassment Policies and Procedures. Please fill
in all of the information requested below as completely as possible and attach additional pages to this form, if
necessary. Forward completed forms and attachments to Employee Relations & Compliance, Human Resources, 215
Central Ave. Ste. 205, Louisville, Kentucky 40208-2770 or to [email protected].
Last Name: _
____
___
___
_
_______________________ First Name: _________________________________
Mailing Address: _________________________________________________________________________________
City: ________________________________________ State: _______ Zip Code: _______________
E-mail: ______________________________________ Home/Mobile Phone: __________________________
Work Phone: _________________________________ Best time to call: __________ AM/PM_______
University ID (if applicable): ____________________
What is your relationship with the University of Loui
sville?
Current Employee? ☐ Yes ☐ No Former Employee? ☐ Yes ☐ No Student? ☐ Yes ☐ No
Applicant for employment? ☐ Yes ☐ No A Third Party? ☐ Yes ☐ No Other? ☐ Yes ☐ No
If you marked ‘Other’ or ‘A Third Party,’ please specify your relationship with the University: _____________________
Indicate the type(s) of complaint being filed: ☐Discrimination
If you are filing a Discrimination or Harassment complaint, in
dicate the Protected Status(es) that was/were the basis(es) of
the alleged Discrimination or Harassment (Please select all that apply):
☐ Race/Color ☐ Religion ☐ Sexual Orientation ☐ Genetic Information
☐ Equal Pay/Compensation* ☐ Pregnancy ☐ Disability ☐ Age
☐ National/Ethnic Origin ☐ Gender Id
entit
y ☐ Militar
y
/Veteran Statu
s ☐
Gender/S
ex**
*(the Equal Pay Act requires men and women in the same workplace be given equal pay for equal work)
** (including sexual harassment & sexual misconduct)
☐Retaliation
☐Harassment
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1. Identify the Respondent who allegedly harassed and/or discriminated against you. For each Respondent, provide the
identifying information requested below:
Respondent’s name: Relationship/Association with UofL: Relationship/Association to you:
2. Describe the incident(s) or event(s), date(s), time(s), and location(s) giving rise to your complaint. Attach additional
pages to this form, if necessary.
3. If you are filing a Sexual Harassment or Sexual Misconduct complaint, including Domestic Violence, Dating
Violence, or Stalking, please describe the conduct, including date(s), time(s), and location(s). Attach additional pages
to this form, if necessary.
4. Describe the specific harm you have suffered resulting from the incident(s).
5. If you or others did something to try to resolve the issue, please describe.
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6. Identify individuals who may have observed or witnessed the incident(s) that you described:
Last Name: ________________________________ First Name: ______________________________
Relationship to UofL: ________________________ Telephone: ______________________________
Last Name: ________________________________ First Name: ______________________________
Relationship to UofL: ________________________ Telephone: ______________________________
Last Name: ________________________________ First Name: ______________________________
Relationship to UofL: ________________________ Telephone: ______________________________
7. Do you have any documents that support your complaint? ☐ Yes ☐ No (Please list and attach a copy)
8. Describe your proposed remedy. Be as specific as possible.
AUTHORIZATION
I certify that the information given in this complaint is true and correct to the best of my knowledge or belief. I
understand that a copy of this complaint will be provided to the respondent.
Print Name of Complainant: _____________________________________________
Signature of Complainant: _______________________________________________ Date: ____________________
For University Use Only: Date Complaint Received: _____________________ Signature: _________________
