Discrimination and Harassment Prevention Policy:

Complaint Submission Form

Section 1: Identifying information

Name:	Click here to enter text.
Email address:	Click here to enter text.
Phone (ext.):	Click here to enter text.

Affiliation:	Faculty	☐	Staff ☐	Student ☐	Other Click here to enter text.

Section 2: Type of Discrimination or Harassment

a. I believe I have been subjected to discrimination or harassment based on: (Check all appropriate items)

☐ Sex	☐ Age	☐ Race/Colour	☐ Nationality
☐ Ethnicity	☐ Pregnancy	☐ Disability	☐ Source of Income
☐ Religion/Creed	☐ Marital/Family Status	☐ Gender Identity	☐ Gender Expression
☐ Sexual Orientation	☐ Medical Condition	☐ Political Belief/Affiliation	☐ Social Disadvantage

b. ☐ I believe I was subjected to personal harassment/bullying.

c. ☐ I believe I was subjected to retaliation.

d. ☐ I believe I was subjected to a malicious complaint.

Section 3: Details of Complaint

Date of most recent or continuing discrimination/harassment:	Click here to enter a date.
Person(s) responsible for the action:	Click here to enter text.
Relationship to the person(s):	Click here to enter text.
Details of incidents(s):	Describe each incident separately, including the person(s) involved, what happened and when, where it happened, and list any witnesses.

Click here to enter text.

By submitting this complaint form to the Diversity and Human Rights Advisor you are requesting an investigation under the Discrimination and Harassment Policy. This requires that your name and the contents of this complaint be shared with the respondent(s). In order to investigate the complaint, some information may also need to be shared with witnesses. All parties to an investigation must respect the confidential and private nature of the process, and share information only where necessary for resolution of the complaint, or where required by law.

Signature Click here to enter text.	Date Click here to enter a date.

For further information, please contact:	Lisa Park | Diversity and Human Rights Advisor

Human Resources | Brandon University

270 18th Street | Brandon, MB R7A 6A9

Tel: 204-727-9785 | Fax: 204-726-1957