Faculty______                    Date Received _________

Staff  ______                    Date Resolved _________

Student______

UNION COUNTY COLLEGE
OFFICE OF AFFIRMATIVE ACTION
CHARGE OF DISCRIMINATION FORM

This form is to be used to file a charge of discrimination based on RACE, COLOR, RELIGION, SEX, NATIONAL ORIGIN, AGE, PHYSICAL DISABILITY, MARITAL STATUS,SEXUAL ORIENTATION or MILITARY CLASSIFICATON.

(Please print or type)

To be completed by the complainant:

1.Your Name _______________  Campus Phone No. ___________

Position  _________________  Dept. ______________________

Home Address ______________  Home Phone No. _____________

City ______________________  State __ Zip Code___________

2.Alleged discrimination was based on:

Race or Color           (   )  Religion      (   )
National Origin         (   )  Sex           (   )
Disability              (   )  Marital Status(   )
Sexual Orientation      (   )  Age           (   )
Military Classification (   )

3.(a) Have you filed this charge with a Federal, State or Local  government agency?

Yes (   )When ____________(Mon/Day/Year)    No (   )

Which agency have you filed with? ______________________

  (b) Have you instituted a suit or court action on this charge?

Yes (   ) When ___________(Mon/Day/Year)      No (   )

In which Court have you instituted suit?________________

4.Alleged discrimination took place on or about __________________(Mon/Day/Year).

Check here if alleged discrimination is continuing _____

5.Describe briefly the act which occurred and your reason for concluding that it was discriminatory (use extra sheet if necessary). Include the name(s), job title(s), and department(s) of the person(s) against whom the complaint is filed.

_________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________

Relief sought: _________________________________________________________ _________________________________________________________

6.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.

__________________        _______________________________
(Date)                                (Sign Your Name)

To be completed by Affirmative Action Officer or supervisor:

7.Resolution of the complaint:

_________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________

__________________        _______________________________
(Date)                    (Signature)

                          _______________________________
                          (Title)

8. Follow-up: _________________________________________________________ _________________________________________________________ _________________________________________________________

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