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Title VI and VII Complaint / Report Form For Allegations or Discrimination

Your Information

Please complete the following:

Name

SBUID#

Street Address

City

State

Zipcode

Type of Daytime Phone

Daytime Phone Number

Type of Evening Phone

Evening Phone Number

May we contact you at work?

Please identify your relationship(s) to the University

If you are an employee, please complete the following:

Job Title

Date of Hire

Department

Union (If applicable)

Supervisor Name / Job Title

OPTIONAL - Complete any categories below that may be relevant this complaint

Race/Ethnicity

Religious Affiliation

Sex/Gender

Nature of Disability

Military Status

Marital Status

Other Relevant Personal Information

What is the nature of your disability?

Did you request an accommodation?

Was an accommodation provided?

If you believe your accommodation is insufficient, please explain here.

If you are having trouble accessing a University facility, please explain here.

What injury have you sustained as a result of this alleged incident (Lost wages, benefits, etc.)

Complaint Information

Please be as complete and specific as possible.

Name(s) of Individual(s) who allegedly violated University policy: (Respondent)?

Please identify Respondent's relationship(s) to the University:

Please identify Respondent's relationship(s) to YOU

Respondent's Title

Respondent's Department

What action are you alleging occurred (Select all that apply)

Date of first incident

Date of Most Recent incident

What do you believe is the basis for the alleged discriminatory behavior (select all that apply)?

Please answer the following questions as thoroughly and completely as possible.

Give a detailed account of anything that happened to you that was discriminatory or violated Stony Brook policy. Please provide dates, name and titles of everyone involved.

Did the respondent provide any justification or reason for their actions?

Did you report the incident(s) to anyone at Stony Brook University? Please detail to whom you reported and the date, time and context of the report

Was anyone else treated the same way you were? If so, please provide their names and any contact information.

Did anyone witness the behavior? If so, please provide their names and any contact information.

Are there any documents, communications, social media posts or other evidence that will support your case? If so, are you able to provide them? Please explain:

What remedy are you requesting?

Please provide any additional information you may feel may be relevant or necessary

Certification

I swear or affirm that I have read the above allegation and that it is accurate to the best of my knowledge, information, or belief.

I understand that I should keep all information learned during the complaint investigation process should be kept confidential by Complainants and Reporting Individuals. The Office of Equity and Access (OEA) keeps all information gathered relative to allegations of discrimination in confidence to the extent practicable or allowable by law. However, OEA may provide relevant information to the appropriate University staff as necessary.

I understand that it is a violation of State and Federal law and Stony Brook University policy for anyone to retaliate against any individual involved in an investigation of discrimination. I understand that if I am subjected to any adverse action that I feel may be retaliatory, it should be reported immediately to OEA.

I understand that the filing of an internal complaint with Stony Brook University is not a waiver of my right to file a formal complaint of unlawful discrimination with the New York State Division of Human Rights, the Equal Employment Opportunity Commission (EEOC), the Federal courts, or the State courts.

I understand that the filing of an internal complaint does not stop the statute of limitations for filing external complaints with EEOC, the NYS Division of Human Rights, litigation, or any other agency hearing such complaints. I am aware that should I choose to file a verified complaint with an outside agency, such a complaint must be filed with EEOC within 180 days of the alleged incident and with the State Division of Human Rights within 365 days of the alleged incident.

I understand policy and the information contained in it does not constitute legal advice. If you require legal advice, consult an attorney. By submitting this form, I am certifying the above statements to be true and factual to the best of my knowledge.

If you like a copy of this form, please provide your email.

Signature (Type your name)

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