Discrimination or Harassment Information Intake Form

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Discrimination or Harassment Information Intake Form

Affirmative Action Officer - Tammy Gouger tgouger@brockport.edu

If you are considering a report of discrimination or harassment and would like to be contacted, please fill out this form.
Name Name * First Last
Banner ID *
Must be 9 digits. Currently Entered: 3 digits.
Phone Phone * - ### - ### ####
Email *
Department *
University Affiliation *
Gender *

Gender Female Male Nonbinary Other Prefer not to say
Would you describe yourself as transgender? *

Would you describe yourself as transgender? Yes No Perfer not to answer
Race/Ethnicity- Check as many as apply. *

Race/Ethnicity- Check as many as apply. White Black/African American Hispanic or Latino Asian American Indian or Alaska Native Native Hawaiian or Other Pacific Islander
Describe the situation or treatment about which you are concerned. Please include specific incidents to the best of your recollection, and include approximate date(s) if possible. *
Are you concerned that this situation or treatment was the result of one or more of the following? *

Are you concerned that this situation or treatment was the result of one or more of the following? Age Criminal Conviction Disability Domestic Violence Victim Status Familial Status Gender Identity or Expression Marital Status Military/Veteran Status National Origin Predisposing Genetic Characteristics Pregnancy Race/Color Religion Retaliation Sex Discrimination Sexual Harassment Sexual Orientation Other Other
Name(s) of the subject of your concern and relationship (ex. supervisor, coworker, instructor) *
Name(s) of any witnesses to the situation or treatment you described
Name(s) of anyone you have spoken to about your concern that is affiliated with SUNY Brockport.
Upload a File- Please include any supporting documents.

Attach Files
What resolution are you seeking?

Main Page Content

Discrimination or Harassment Information Intake Form

If you are considering a report of discrimination or harassment and would like to be contacted, please fill out this form.