Charge of Discrimination Form

This form may be used by a current or former SUNY student or employee, or by a Third Party, to file a complaint under Section I of SUNY Procedure 6501 alleging Discrimination, Harassment, and/or Retaliation. You do not need to complete this form to report possible Discrimination, Harassment, or Retaliation to SUNY. Reports may be made verbally or in writing to the appropriate Campus office. A report does not, by itself, constitute the filing of a complaint under Section I. The Campus will assess reports and respond as appropriate, even when this form is not submitted. The Campus will determine the procedure applicable to the allegations and will advise you if another SUNY grievance procedure applies. Campus staff are available to assist with completing this form.

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PART I — ADMINISTRATIVE AND CONTACT INFORMATION

This Part is maintained for administrative and investigative purposes and does not constitute the complaint under Section I of Procedure 6501. Part I will not be provided to the Respondent as part of the complaint. Information contained in Part I may nevertheless be disclosed when required by law or as necessary to administer the complaint process.
1. COMPLAINANT INFORMATION
Frist Name:
Last Name:
Campus/Office Phone: Campus/Office Phone: - ### - ### ####
Campus Address: Campus Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
SUNY Status: (check all that apply):

SUNY Status: (check all that apply): Applicant Contractor/Vendor Employee Former employee Former student Graduate student Intern/Volunteer Student employee Undergraduate student Visitor Other (Third Party)
Preferred email:
Preferred telephone: Preferred telephone: - ### - ### ####
Mailing address, if needed: Mailing address, if needed:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Preferred method of contact:
2. PERSON ASSISTING THE COMPLAINANT WITH THIS FORM, IF ANY

A person may report or refer information concerning possible Discrimination, Harassment, or Retaliation without filing a complaint on behalf of the person alleged to have experienced the conduct. A report or referral does not, by itself, constitute a complaint under Section I by that person. The Campus will assess the information and determine the appropriate process, if any, for response.
Name:
Relationship to Complainant:
Contact information:
3. WITNESSES OR OTHER PERSONS WHO MAY HAVE RELEVANT INFORMATION
Number of witnesses: (maximum of 6):
Witness #1:
Name:
Phone: Phone: - ### - ### ####
Email:
What did they witness?
Witness #2:
Name:
Phone: Phone: - ### - ### ####
Email:
What did they witness?
Witness #3:
Name:
Phone: Phone: - ### - ### ####
Email:
What did they witness?
Witness #4
Name:
Phone: Phone: - ### - ### ####
Email:
What did they witness?
Witness #5:
Name:
Phone: Phone: - ### - ### ####
Email:
What did they witness?
Witness #6:
Name:
Phone: Phone: - ### - ### ####
Email:
What did they witness?
4. RESPONDENT INFORMATION
Name:
Campus Address/Contact Information (if known):
5. OTHER FILINGS OR PROCEEDINGS

Note: Filing a complaint with SUNY does not extend any deadline for filing with an outside agency or court.
Have you filed a complaint concerning this matter with an outside agency?

Have you filed a complaint concerning this matter with an outside agency? No Yes
Agency:
Date: Date: / MM / DD YYYY
Have you commenced a lawsuit or other court proceeding concerning this matter?

Have you commenced a lawsuit or other court proceeding concerning this matter? No Yes
Court/Tribunal:
Date: Date: / MM / DD YYYY
Case/Index No., if known:
Contact information, if known:
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Charge of Discrimination Form

Charge of Discrimination Form

PART I — ADMINISTRATIVE AND CONTACT INFORMATION

1. COMPLAINANT INFORMATION

2. PERSON ASSISTING THE COMPLAINANT WITH THIS FORM, IF ANY

3. WITNESSES OR OTHER PERSONS WHO MAY HAVE RELEVANT INFORMATION

Witness #1:

Witness #2:

Witness #3:

Witness #4

Witness #5:

Witness #6:

4. RESPONDENT INFORMATION

5. OTHER FILINGS OR PROCEEDINGS