Reporting Person's Information

Name: *  
Street Address: *
City: *
State: * Illinois Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code: *  (11111)
Home Phone: *  (111) 111-1111
Mobile Phone:  (111) 111-1111
CCC Affiliation: * None Employee Student Employee and Student Other  
Other Affiliation:

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Incident Submission Information

Incident Date: *    
Department: *  
CCC Location: * None District Office Harold Washington Harry S Truman Kennedy-King Malcolm X Olive-Harvey Richard J. Daley Wilbur Wright Arturo Velasquez Institute Dawson Technical Institute French Pastry School South Chicago Learning Center Washburne Culinary Institute West Side Learning Center Wright College Humboldt Park Other  

Location where incident may have occurred (If 'Other' selected in 'CCC Location' field above):

Name of the individual I am filing this Equal Opportunity/Title IX Complaint against: *

 

Is the person that the complaint is being filed against an employee or a student? *

EmployeeStudent  

Provide the name(s) and telephone number(s) of any witness (es) to the incident.

Witness One Name:
Witness One Type: None Employee Student
Witness One Phone:  (111-111-1111)
Witness Two Name:
Witness Two Type: None Employee Student
Witness Two Phone:  (111-111-1111)

Basis of Discrimination or Harassment (check all selections that may apply)  *

AgeCitizenshipDating/Domestic Violence
DisabilityEthnicityGender
Genetic InformationMarital StatusNational Orgin
PregnancyRaceReligion
RetaliationSexual AssaultSexual Harassment
Sexual OrientationStalkingVeteran Status
Membership or participation in an organizationOther
 

If "Other" selected in the "Basis of Discrimination" question above enter reason below:

Has an Incident Report been filed with a CCC Office of Safety and Security?  *

YesNo  
Incident Report Date:  

Has a police report been filed with the City of Chicago Police Department?  *

YesNo  
Police Report Date:  

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Description of Incident

The fact(s) of the incident which lead me to believe I was discriminated against or harassed were as follows (attach supporting documents, images or other materials). *

Supporting File Upload #1:  
Supporting File Upload #2:  
Supporting File Upload #3:  
Supporting File Upload #4:  
Supporting File Upload #5:  

Acceptable file formats include .doc, .docx, .png, .gif .jpg or .pdf less than 2MB (megabytes) each.

Requested remedy:

Electronic Signature: *  (Enter Full Name)