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INTAKE QUESTIONNAIRE

COMPLETE THIS INTAKE FORM TO REPORT DIRECTLY TO THE OFFICE OF EQUAL OPPORTUNITY AND THE TITLE IX COORDINATOR

YOU MAY USE ETHICSPOINT TO SUBMIT AN ANONYMOUS REPORT

 

To which gender identity do you most identify?*
Employment Status*
Preferred Method of Contact*
What is the reason (basis) for your claim of discrimination or harassment?*
Complaint Acknowledgement*

As the complainant, I certify to the best of my knowledge the information that I have provided is accurate and the events and circumstances are as I have described them.

I have attached to this complaint any supportive evidence and/or documentation such as e‐mails, records, and/or materials which I believe supports my allegation. I also understand and consent to the disclosure of information contained in this complaint to appropriate administrators and witnesses interviewed for the purpose of investigating this complaint. I understand that I will have to provide contact information of witnesses identified in this complaint. I am willing to cooperate fully in the investigation and provide whatever evidence the University deems relevant. I understand that the nature of this complaint, correspondence, and all discussions conducted in the course of investigation of the information contained in this complaint are confidential to the extent permitted by law and University policy, and unauthorized disclosures of information concerning the investigation could result in disciplinary action.  I agree to abide by these guidelines.


I certify the above statement.*
Please email eeo@okstate.edu additional documentation such as letters, emails, memos, notes, etc., you think might be important to complete your response.


 

 

 

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