COMPLAINT INFORMATION REPORT
Please complete and return to the Affirmative Action Office, 328 Boucke Building, University Park, PA 16802
Phone: (814) 863-0471
Fax: (814) 863-7799
Email: aao@psu.edu
Definitions: Please see definitions for Discrimination, Harassment and Retaliation on the last
page of this form.
Name of person bringing complaint:
Date:
Department:
Phone (w):
Supervisor:
Faculty
Staff
Job Title:
Phone (h):
Phone:
Type of complaint
____Harassment
____Discrimination
Basis of complaint:
____Age
____Race Discrimination
____Color
____National Origin
____Religion
____Creed
____Service in the Uniformed Services
(as defined in state and federal law)
____Veteran status
____Sex
Student
____Retaliation
____Sexual Orientation
____Marital or Family Status
____Pregnancy
____Pregnancy-Related Conditions
____Physical or Mental Disability
____Gender
____Perceived Gender
____Gender Identity
____Genetic Information
____Political Ideas
(1) Explain what has occurred which leads you to believe you have been subjected to
discrimination, harassment and/or retaliation. (Please be specific) (Use additional sheet if
necessary.)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
(2) Where and when did the incident(s) occur? (Please be specific)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
(3) Who do you feel is responsible for the alleged discrimination, harassment or retaliatory
act/behavior? (Please provide names and job titles of all individuals involved)
Name
Title
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
(4) Why do you feel the alleged behavior/incident(s) is discriminatory, harassment or retaliation?
Explain
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
(5) Please list all witnesses that may have heard or seen the incident(s).
Name
Title
Phone
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
(6) Please provide the names and job titles of others who were not witnesses, but might be able
to support your allegation of discrimination, harassment or retaliation.
Name
Title
Phone
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
(7) Do you have any documentation or evidence to support your claim of discrimination,
harassment or retaliation?
_______Yes
______No
(If Yes, please attach a copy to this form)
(8) Have you tried to address the situation by discussing it with your supervisor or others? (If
yes, please provide information below.)
Name
Date
Outcome
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
(9) What outcome are you seeking?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
(10) Do you wish to proceed with:
Informal resolution______
Formal investigation______
Think further about processing complaint______
_______________________________________
Signature
______________________________
Date
Definitions:
Discrimination
Conduct of any nature that denies an individual the opportunity to participate in or benefit from a
University program or activity, or otherwise adversely affects a term or condition of an
individual’s employment, education, or living environment, because of the individual’s age, race,
color, ancestry, national origin, religion, creed, service in the uniformed services (as defined in
state and federal law), veteran status, sex, sexual orientation, marital or family status, pregnancy,
pregnancy related-conditions, physical or mental disability, gender, perceived gender, gender
identity, genetic information or political ideas.
Harassment
A form of discrimination consisting of physical or verbal conduct that substantially interferes
with an individual’s employment, education or access to University programs, activities or
opportunities. Harassment may include, but is not limited to, verbal or physical attacks, graphic
or written statements, threats, or slurs. Whether the alleged conduct constitute prohibited
harassment depends on the totality of the particular circumstances, including the nature,
frequency and duration of the conduct in question, the location and context in which it occurs
and the status of the individuals involved.
Retaliation
Adverse action taken by a member of the University faculty, staff, or student body against any
individual on the basis of a good faith report made by such individual, or on the basis of such
individual’s participation in an investigation, hearing, or inquiry by the University or an
appropriate authority, or participation in a court proceeding relating to suspected wrongful
conduct at the University. Retaliation shall include, but not limited to, harassment,
discrimination, treats of physical harm, job termination, punitive work schedule or research
assignments, decrease in pay or responsibilities, or negative impact on academic progress.
AAO/cbb/revised/11/15