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Student Discrimination Complaint Form

Person alleging discrimination/harassment or person referring the complaint


I wish to remain anonymous. I understand that Title IX may require the College to investigate and take reasonable action in response to the information I provide on this form. I also understand that this may limit the College's ability to respond to my complaint.

Name:

Student Number (if applicable):

Department (if applicable):

Email:

Contact Address:

Phone number: (Daytime)

(Evening):

LCC Status:

Faculty/Staff

Student

Other

If Other (Please Specify):


Person who is accused of discrimination/harassment: Please include as much information as possible. If information is unknown, please leave blank.


Name:

Student Number (if applicable):

Department (if applicable):

Email:

Contact Address:

Phone number: (Daytime)

(Evening):

LCC Status:

Faculty/Staff

Student

Other

If Other (Please Specify):


Describe specific act(s) alleged with name(s), date(s), time(s) and location(s) if possible.


Basis of Discrimination/Harassment:

Race/Color

Age

Sexual Misconduct/Sexual Orientation/Gender Identity

Gender

National Origin/Creed/Ancestry

Disability

Sexual Orientation

Height

Weight

Religion

Retaliation

Veteran Status

Other (Please Specify):

Were there any witnesses present for the alleged behavior?

Yes

No

If yes, please list names and contact information: (including phone number, address, student number (if applicable), email, etc..)

If alleging harassment, did you take any action to stop the harassment?

Yes

No

If yes, please summarize the action taken:

Other than this report, did you ever report the alleged discriminatory behavior to an employee of the college?

Yes

No

If yes, please state the name of the employee and the date you reported it to them:

How would you like to see this situation resolved?


Equal Opportunity and Diversity Programs at Lansing Community College

Office of Risk Management and Legal Services
WCP 150
Phone: (517) 483-1730