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Complaint of Discrimination/Harassment - Students

Answer any questions as completely as possible.   If you do not know the answer to the question, please respond by stating “not known.”  If the question is not applicable, please write “N/A.”

Required fields marked with an (*)

1. Personal Information

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Best time of day to call you: *

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2. Who else can we call if we cannot reach you?

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3. Who was discriminated against?

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If the person discriminated against is age 18 or older, we will need that person's signature before we can proceed with this complaint. If the person is a minor, and you do not have legal authority to file a complaint on the student's behalf, the signature of the child's parent or legal guardian is required.

4. The college, department or office at Radford University that allegedly discriminated?

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5. Have you filed a complaint through the institution's grievance process, due process hearing, or with another agency? *

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6. Describe the Discrimination

The Office of Equity and Diversity reviews prohibit discrimination on the basis of race, color, national origin; sex; sexual orientation, disability; and/or age.

On what basis were you discriminated against? (You may select more than one) *

 Race
 Color
 National Origin
 Age
 Sex Discrimination
 Sexual Harassment
 Sexual Orientation
 Disability
 Retaliation because you filed a complaint or asserted your rights
 Sexual violence
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In the space provided below please describe each discriminatory action separately.  For each action, you need to provide the following information: *

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Why you believe the discrimination was because of race, sex, disability, sexual violence or whatever basis you indicated above or why it was retaliatory? *

 
 
 
 

Why you believe the discrimination was because of race, sex, disability, sexual violence, or whatever basis you indicated above or why it was retaliatory?

 
 
 
 

Why you believe the discrimination was because of race, sex, disability, sexual violence, or whatever basis you indicated above or why it was retaliatory?

 
 
 
 

Why you believe the discrimination was because of race, sex, disability, sexual violence, or whatever basis you indicated above or why it was retaliatory?

 
 
 
 

Why you believe the discrimination was because of race, sex, disability, sexual violence, or whatever basis you indicated above or why it was retaliatory?

Do you have written information that you think will help us understand your complaint? *

7. Your complaint must be filed within 180 days of the discriminatory action

The laws require that complaints be filed with our office within 180 days of the alleged discriminatory event.

When did the last act of discrimination occur?

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8. What would you like Radford University to do as a result of your complaint - what remedy are you seeking? *

Verification

I, the undersigned, certify that this document is a complete and accurate statement of my complaint. I, further understand that the information provided herein will be kept private, but not confidential within the university, and may be reviewed by the University personnel and employees to determine the existence of facts relevant to this complaint. 

By signing this document, I consent to the review, processing, investigation, and disclosure of this enclosed information by the Office of Diversity and Equity as stated above. I will cooperate with the Office of Diversity and Equity’s investigation and complaint resolution activities.  I understand that my failure to cooperate with the Office of Diversity and Equity’s investigation may result in the closure of my complaint.  I further verify that I have been provided with a copy of Radford University Discrimination Complaint Procedure.    

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Radford University does not discriminate based on the basis of race, color, age, disability, National Origin, gender, religion, sexual orientation, or retaliation.