ࡱ> :<9_ bjbj 7*>\>\! 88888LLL8$4LG!.&&&  $u"+%b 8q&&qq 884!q^88 q XMuaOp !0G!x,%uH%&%8&0V"x&&& Z&&&G!qqqq%&&&&&&&&&> :  STATE UNIVERSITY OF NEW YORK CHARGE OF DISCRIMINATION This form can be used by students, employees, and third parties to file a complaint of discrimination based on race, color, national origin, religion, creed, age, disability, sex, gender identity, sexual orientation, familial status, pregnancy, predisposing genetic characteristics, military status, domestic violence victim status, or criminal conviction. CAMPUS______________________________ (PLEASE PRINT OR TYPE) RECEIVED BY__________________________ DATE _______________ Name________________________________ Phone _________________________________ Campus Address____________________________ Status:_____________________________________ (Faculty, Staff, Graduate, Undergraduate) Home Address______________________________ City______________________________ State_______________ Zip Code_________________ ALLEGED DISCRIMINATION IS BASED ON (please list all that apply): _______________________________________________________________________________________ Alleged Discrimination took place on or about: Month__________ Day_______ Year________ Location of alleged discrimination:______ _____________________ Check if alleged discrimination is continuing ( Yes ( No Respondent(s) Name(s) ________________________________ Title (if known) _______________________ Address: ___________________________________________ Status: _____________________________ (Faculty, Staff, Graduate, Undergraduate) Telephone: _________________________________________ Witness(es) Names and contact information (attach additional pages if needed):_______________________ _______________________________________________________________________________________ Please check the appropriate box(es): I have filed an informal complaint on _________________________(Date). I have reported information concerning this matter on _____________________(Date). I elect to utilize the informal complaint process as described in the Discrimination Complaint Procedure. I elect to proceed immediately to file a formal complaint as described in the Formal Resolution section of the internal Discrimination Complaint Procedure. Have you filed this charge with a federal, state or local government agency? ( Yes ( No If yes, with which agency?_________________________________ When?________________________ Have you instituted a suit or court action on this charge? ( Yes ( No If yes, with which court?______________________________________ When? ______________________ Court address ______________________________________________________________________________ Contact person_________________________________________________ Describe briefly the act which occurred and your reason for concluding that it was discriminatory (attach extra pages if necessary). Describe any corrective or remedial action you would like to see taken (attach extra pages if necessary). I agree to provide such other or supplemental information that may be requested. I swear or affirm that I have read the above charge and that it is true to the best of my knowledge, information and belief. Signature:________________________________________________________ Date_______________     Form A Form A:  HYPERLINK "http://www.suny.edu/sunypp/documents.cfm?doc_id=451" 91 Procedure, Doc. No. 6501. 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