DISCRIMINATION AND/OR SEXUAL HARASSMENT INTAKE FORM
Please print this form and return to EIU, Office of Civil Rights & Diversity,108 Old Main, Charleston, IL 61920.
Name:______________________________ Department:____________________________
Date:_______________________________ Phone: (w)______________(h)_____________
Issue Regarding_____________________________________________________________

Please explain why you believe that you have been discriminated against or sexually harassed. When and Where did the incident(s) occur? Who was involved? Any other information. Attach additional sheets if necessary.

 

 

 



Others who may have knowledge or information:

 

 

 

 


Remedy Sought

 

 

Complainant's signature __________________________________________________________

10/2002