Discrimination Complaint Form - Equal Opportunity & Access

Equal Opportunity & Access

Western Illinois University
Office of Equal Opportunity and Access
Discrimination Complaint Form

This form is to be used by students, faculty, staff, and applicants for employment to file a complaint of discrimination based on sex, race, color, sexual orientation, gender identity and gender expression, religion, age, marital status, national origin, disability, or veteran status or any other category protected by the State of Illinois or by federal law.

If you prefer to submit a complaint form via mail, please access our printable PDF version.

COMPLAINANT INFORMATION:

Please list the address, telephone number, and email to which you wish to receive communications regarding this complaint.

Name:

Title:

Address:

City:

State:

Zipcode:

Primary Contact Telephone:

Alternate Contact Telephone:

Email:

University Status:
Faculty
Staff
Student

RESPONDENT(S) INFORMATION (if known):
Name:

Title:

Name:

Title:

ALLEGED DISCRIMINATION FACTORS:
Age National Origin Race
Veteran Status Disability Religion
Sex Sexual Orientation
Sexual Harassment Color Gender Identity/Expression
Marital Status Retaliation
Other

PLEASE ENTER A STATEMENT WHICH OUTLINES THE NATURE OF THE COMPLAINT AND YOUR
REASON(S) FOR CONCLUDING THAT IT WAS DISCRIMINATORY*. PLEASE INCLUDE THE REMEDY SOUGHT.

Date Submitted:

* Respondent(s) will be notified at the time the complaint is filed to respond to the complaint.

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