Discrimination/Harassment Complaint Intake Form
The James Madison University Office of Equal Opportunity will accept complaints of discrimination or
harassment on the basis of age, race, color, national origin, gender, religion, sexual orientation,
veteran’s status, political affiliation, or disability. This procedure also may be used by those who believe
that they have been subjected to sexual harassment.
To file a complaint, complete form and send a paper copy to
Office of Equal Opportunity
1017 Harrison Street, JMAC 2
MSC 5802
James Madison University
Harrisonburg, VA 22801
Fax: 540-568-7992
For more information, call (540) 568-6991
1) Fill out all applicable fields:
Name
Street Address
City, State, Zip
Home Phone
Business Phone
Email
2) Nature of discrimination/harassment:
(Click in box & check all that apply) ☐ Race
☐ National Origin
☐ Gender
☐ Veteran Status
☐ Sexual Orientation
☐ Sexual Harassment
☐ Color
☐ Religion
☐ Age
☐ Over 40?
☐ Political Affiliation
☐ Disability
☐ Retaliation
3) Describe alleged discrimination and/or harassment. Attach additional pages as needed.
4) Your Relationship to JMU:
(Click in box to select)
☐ Faculty
☐ Classified Staff
☐ Student
☐ Teaching Asst/Grad Asst
☐ Academic Professional
☐ Student Applicant
☐ Administrator
☐ Wage/Temporary Employee
☐ Student Employee
☐ Service Professional
☐ Job Applicant
☐ Other – please describe:
5) Your Employee/Student Information:
Date of Hire/Year in School
College/Department
Job Title/Major
6) Persons you believe are discriminating against or harassing you. Please attach extra paper if your
complaint is against additional people.
Name
Name
Department
Department
Position
Position
Phone
Phone
7) Persons you believe may have knowledge of the discriminatory or harassing treatment that you
received. Please attach additional pages if necessary.
Name
Name
Department
Department
Position
Position
Phone
Phone
James Madison University does not discriminate on the basis of race, color, national origin, religion,
gender, age, veteran status, political affiliation, sexual orientation or disability.
OEO office use only:
Date received
Received by