KANSAS STATE UNIVERSITY
OFFICE OF INSTITUTIONAL EQUITY
DATA INTAKE FORM
Name: _______________________ ______________ ___________ ___________________________________
First
Middle
Last
Home Address: _____________________________________________________________________________
Street or P.O. Box
Phone: Day ________________________
City
State
Zip
Evening ___________________________
E-Mail Address: ____________________________________________________________________________
K-State Department: __________________________ K-State eID:__________________________________
I am a:
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KSU Student KSU Staff KSU Faculty Other: _________________________
Have you been to this office previously? Yes / No
If ‘yes’, date of visit: _______________________
Please briefly describe why you are visiting the Office of Institutional Equity:
___________________________________________________________________________________________
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___________________________________________________________________________________________
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Data Intake Form
Name: ____________________________________________________________________________
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Person Causing Harm #1:
Name: ____________________________________________________________________________
Job Title: __________________________________________________________________________
Department: _______________________________________________________________________
Date(s) of Harm: Earliest: ________________ Latest: _____________
Continuing Harm: Yes / No
Person Causing Harm #2:
Name: ____________________________________________________________________________
Job Title: __________________________________________________________________________
Department: _______________________________________________________________________
Date(s) of Harm: Earliest: ________________ Latest: _____________
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Continuing Harm: Yes / No
Data Intake Form
Name: ____________________________________________________________________________
Basis of Harm: Select all that apply.
Age: _____________
Medical Condition/FMLA
Sexual Assault (incl.
nonconsensual sex)
Citizenship:________
National Origin:_________
Stalking
Color:_____________
Race/Ethnicity/Ancestry
Sexual Orientation
Disability
Domestic/Romantic/
Dating Violence
Religion:________________
Bullying
Veteran Status
/Military Status
Gender:(Male/Female)
Gender Identity /
Gender Expression
Retaliation
Sexual Harassment /
Sexual Misconduct
Other:_____________
Employment or Academic Harm: (optional)
Discipline
Failure to Renew/Reappoint
Demotion
Failure to Accommodate
Reduction in Force
Sexual
Harassment/Misconduct
Failure to Hire
Suspension
Failure to Promote
Termination
Academic performance/grade
Participation in universitysponsored event or program
Housing Environment
Other_____________
Acknowledgment:
I certify that to the best of my knowledge the information that I have provided is accurate.
I understand that this data intake form, any correspondence, and all discussions pertaining to this complaint
process are confidential to the extent permitted by law. I agree to abide by these guidelines.
Signature: ________________________________________
Date: _________________________________
Please return this form to:
Office of Institutional Equity, 103 Edwards Hall, Kansas State University, Manhattan, KS 66506.
Phone: 785-532-6220; Fax: 785-532-4374; Email: equity@k-state.edu
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