INTAKE QUESTIONNAIRE FORM
Central New Mexico Community College (CNM) encourages employees to resolve problems or issues
informally with the individuals involved. However, if you have a concern or experience a problem that affects
you or your co-workers, we ask that you complete this form and return it to Human Resources (HR) within
thirty (30) days after the last incident or problem occurred.
When this form is received in HR, HR will review it to determine the appropriate action. HR may disclose
information from this form to other state, local, and federal agencies as appropriate or necessary to carry out
the College’s functions, or if the College becomes aware of a civil or criminal law violation. Submission of
this form does not preclude an individual from filing a complaint with an external agency nor does it extend
any time limits imposed by law.
Answer all questions as completely as possible, and attach additional pages if needed to complete
your responses. If you do not know the answer to a question, answer by stating “not known.” If a
question is not applicable, write “N/A.”
Section 1: Personal Information
Your First Name:
Last Name:
CNM ID Number:
Job Title:
Supervisor Name:
Supervisor Title:
Department:
Date Hired in Current Position
Date Hired at CNM:
Home Phone:
Work Phone:
Cell Phone:
Email Address:
Race:
Color:
National Origin:
Sex/Gender:
Age:
Section 2: Incident Information
Date/Time of Incident:
Location of Incident:
Description of Incident. What happened to you, or to others that you believe was a violation of CNM
Policy? Include the date(s) of the alleged harm, the action(s), and the name(s) and title(s) of the person(s)
involved.
What is the reason (basis) for your claim?
Race
Religion
Veteran Status
National Origin
Disability
Sexual Harassment
Sex/Gender
Pregnancy
Sexual Orientation
Retaliation
Age
Other - Please State:
1|Page
Revised 5.11.15
If your claim is retaliation, then what legal action did you participate in?
Are there any witnesses to the behavior you identified? If yes, please identify the witnesses and tell us what
they may say.
Describe who was in the same or similar situation as you and how they were treated.
Do you have any documents to support your claim of discrimination/harassment/retaliation?
Have you filed a charge previously on this matter with the EEOC or another agency?
Yes
No
If you filed a complaint with another agency, provide the name of agency and the date of filing:
Have you sought help about this situation from any other internal or external source?
What ideas do you have for remedying the situation?
Is there any other information you feel is relevant to this situation?
HR USE ONLY
Date Received:
Investigation Conducted:
Date Closed:
Investigator:
HR Consultant:
Investigation #:
Yes
No
Date Investigation Started:
Referred to Department/Manger:
Yes
No
Referred to Other:
2|Page
Submit completed form to your HR Consultant. To find your consultant go to Contact Human Resources
on the HR webpage.
Revised 5.20.15