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Information Intake Form

Affirmative Action Officer - Christiana Ortiz cortiz@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 *
  • Must be 9 digits.   Currently Entered: 3 digits.
  • Phone Phone * - -
  • Gender *
    Gender
  • Would you describe yourself as transgender? *
    Would you describe yourself as transgender?
  • Race/Ethnicity- Check as many as apply. *
    Race/Ethnicity- Check as many as apply.
  • 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?
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