AC-E ©

EXHIBIT

NONDISCRIMINATION / EQUAL OPPORTUNITY

COMPLAINT FORM -
DISCRIMINATION, HARASSMENT, OR RETALIATION
(To be filed with the compliance officer as provided in AC-R)

Please print:

Name ______________________________________ Date __________________

Address _____________________________________________________________

Telephone _____________ Another phone where you can be reached ____________

During the hours of ____________________________________________________

E-mail address ________________________________________________________

I wish to complain against:

Name of person, school (department), program, or activity ______________________

_____________________________________________________________________

Address ______________________________________________________________

Specify your complaint by stating the problem as you see it. Describe the incident, the participants, the background to the incident, and any attempts you have made to solve the problem. Be sure to note relevant dates, times, and places.

_____________________________________________________________________

If there is anyone who could provide more information regarding this complaint, please list name(s), address(es), and telephone number(s).

Name Address Telephone Number

_____________________________________________________________________

The projected solution

Indicate what you think can and should be done to solve the problem. Be as specific as possible.

_____________________________________________________________________

I certify that this information is correct to the best of my knowledge.

_____________________________________________________
Signature of Complainant

The compliance officer, as designated in AC-R, shall give one (1) copy to the complainant and shall retain one (1) copy for the file.