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Complaint Form
If you see this don't fill out this input box.
Date
Complainant Name
Address
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Complainant E-mail
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Select One
Student
Employee
Discrimination based on: (please select)
sex (including sexual harassment and assault, domestic violence, dating violence and stalking)
sexual orientation
gender identity
Describe the specifics of complaints including dates of alleged discrimination or sexual misconduct
Describe any corrective action that you are seeking with regard to the alleged discrimination or sexual misconduct
Provide the name/s against whom your complaint is filed (when possible, please note title)
If anyone witnessed these events, please list their names, titles and a summary of what you believed they witnessed:
Full Name
Title
Summary
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Full Name
Title
Summary
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Full Name
Title
Summary
Please confirm
To the best of my knowledge, I affirm that all of the factual information on this form is accurate.
Submitted forms go to the Office of Social Equity
210
Carrier Hall, Clarion University of Pennsylvania, Clarion, PA 16214
Title IX Coordinator:
Amy Salsgiver:
asalsgiver@clarion.edu
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Last Updated 8/7/20