Complaint Form

Please complete the following form to submit a complaint to the Office of Diversity and Equity Compliance. View the Title IX complaint flowchart (PDF) to understand the process once a complaint is received.

Reporting Party [person making the complaint]

Reporting party name*

Reporting party title

Is reporting party the alleged victim*

Yes No

Department

Daytime phone

Campus address

Home address

Home phone

Cell phone

Email

Status*

Student Faculty Staff Other

If Other, please provide

Request confidentiality*

Yes No

Preferred contact method

Basic of Complaint

Check all that apply. Basis should be discrimination or harassment based on protected category or a complaint related to a form of Sexual Misconduct.

Basis of complaint*

Age

Ethnicity

National Origin

Race

Religion

Pregnancy

Disability

Sexual Orientation

Gender Identity

Veteran Status

Sex/Gender

Genetic information

Domestic Violence

Dating Violence

Sexual Exploitation

Stalking

Sexual Harassment

Sexual Assault

Sexual Battery

Pregnancy

Sexual Orientation

Gender Identity

Retaliation for DEC complaint/ investigation

Other

Reported to Police

Reported to police

Yes No

If Yes, which police department?

GGCPD Gwinnett PD Other Police Department

Other Police Department

Respondent [person alleged to have violated the Policy]

Respondent name*

Respondent title

Department

Daytime phone

Campus address

Home address

Home phone

Cell phone

Email

Status

Student Faculty Staff Other

If Other, please provide

Details of Complaint

Date of incident*

Time of incident*

Location of incident*

Describe each incident of harassment, discrimination, sexual misconduct, or retaliation separately. Please be as detailed as possible, giving names, dates and places, include phone numbers and addresses if possible. Use additional pages if needed.*

Witnesses

List those witnesses you believe have information about your complaint. Include complete information for each witness listed. If the Reporting Party is not the alleged victim, please identify the alleged victim as a witness below. Add additional pages if necessary.

Witness #1

Name

Title

Address

Work phone

Home phone

Cell phone

Email

Status

Student Faculty Staff Other

If Other, please provide

What information can witness provide?

Witness #2

Name

Title

Address

Work phone

Home phone

Cell phone

Email

Status

Student Faculty Staff Other

If Other, please provide

What information can witness provide?

Witness #3

Name

Title

Address

Work phone

Home phone

Cell phone

Email

Status

Student Faculty Staff Other

If Other, please provide

What information can witness provide?

Supporting Materials/Documents

List and produce any written materials or other documents you believe may help in investigating your complaint. Please include social media or text communications if available. Items may be physically provided or electronically provided.

Supporting Materials/Documents

Upload/attach supplemental documents

Attachment 1

Attachment 2

Attachment 3

Additional Information

Have you previously reported or otherwise complained about this or related acts of harassment, discrimination or retaliation to a College supervisor or official? If so, please identify the individual to whom you made the report, the date you made the report and the resolution.

Additional Information

What would resolve this complaint? What type of outcome are you seeking?

By checking this box, I affirm that I have read the above information and it is true to the best of my knowledge and belief.*

Do not fill in this field: