Grievancesubmit

East Carolina University
Office of Equal Opportunity & Equity

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Grievance Form

Date:

mm/dd/yy

Check One:

Faculty

Staff

Student

Employment Applicant

Other

Name:

Department:

Work Telephone:

Work Address:

Work City:

Work State:

Work Zip:

Home Telephone:

Home Address:

Home City:

Home State:

Home Zip:

ECU ID:

E-mail Address:

Name of Your Supervisor:

Supervisor's Telephone:

Other's with Knowledge of Issue:

Have you brought this matter to the attention of any other department(s) at the University? If so, please list the name(s) and department(s) of all other persons with whom you have discussed this matter.

Inquiry Only

Please check this box if you agree with the following: I request that the Equity Office does not investigate the issues that I have reported. Please treat as an inquiry only and keep on record for future reference. I understand that depending on the seriousness of the behavior, the Equity Office may be required to investigate this issue. I Understand that the Equity Office reserves the right to contact and follow up with the Dept. of Human Resources or Dean of Students regardless of this request.

Complaint Type:

Age

Color

Creed

Disability

National Origin

Race

Religion

Retaliation

Sex/Gender

Sexual Harassment

Sexual Orientation

Veteran Status

Please enter the type of complaint, check one or more.

Complaint:

Describe your complaint and include relevant dates that the alleged behavior occurred. (Please summarize above.)

Accused:

Name of person or persons you believed discriminated against you and why you have contact with them (i.e.. Supervisor, co-worker, faculty, customer)

Corrective Action:

Describe the corrective action you are seeking. (Please summarize above.)

Witness 1:

Relationship with Witness 1:

Witness 1 Telephone:

Witness 2:

Relationship with Witness 2:

Witness 2 Telephone:

Additional Info:

Please give us any additional information that we may need.

Certification

Check here to certify that all the above information is true and correct.

Bolded Fields Required.