Reporting Person's Information

Name: * Required Invalid Format
Street Address: * Required Invalid Format
City: * Required Invalid Format
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 Required Invalid Format
Zip Code: *  (11111) Required Invalid Format
Home Phone: *  (111) 111-1111 Required Invalid Format
Mobile Phone:  (111) 111-1111 Invalid Format
CCC Affiliation: * None Employee Student Employee and Student Other Selection Required
Other Affiliation: Invalid Format

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Incident Submission Information

Incident Date: * Required Invalid Format
Department: * Required Invalid Format
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 Selection Required

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: *

Required Invalid Format

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

Employee

Student

Required

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

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

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

Age	Citizenship	Dating/Domestic Violence
Disability	Ethnicity	Gender
Genetic Information	Marital Status	National Orgin
Pregnancy	Race	Religion
Retaliation	Sexual Assault	Sexual Harassment
Sexual Orientation	Stalking	Veteran Status
Membership or participation in an organization	Other

Checkbox selection required in the Basis of Discrimination or Harassment section.

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?  *

Yes

No

Required
Incident Report Date: Invalid Format

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

Yes

No

Required
Police Report Date: Invalid Format

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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: *Invalid File Format
Supporting File Upload #2: *Invalid File Format
Supporting File Upload #3: *Invalid File Format
Supporting File Upload #4: *Invalid File Format
Supporting File Upload #5: *Invalid File Format

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

Requested remedy:

Electronic Signature: *  (Enter Full Name) * Required Invalid Format