image 1Biology Department

Graduate Programs

This form is designed to provide Adelphi University students, staff, faculty, vendors or visitors with an on-line method to report specific information related to an alleged incident(s) of discrimination, harassment (including sexual misconduct), or retaliation.

You are not required to complete the entire form in order for the allegation to be submitted. The University will use the information provided to begin an investigation, which may include contacting the complainant, respondent, and/or any potential witnesses. However, if the report does not contain specific information, the University's investigation and response may be limited.


Complainant Information*:

Are you a: student employee vendor visitor applicant

If you wish to identify yourself, please provide the information listed below:

Last Name:
First Name: MI:
Address:
City, State ZIP:  
Contact Number:  
Email:


* If the person completing this form is the alleged victim (hereafter referred to as victim), you may choose to identify yourself or not. If you are a third party complainant who is not the victim, include the victimís identifiable information only if the victim wishes.

* Victims completing this form who provide personally identifiable information can expect the University to follow-up with an appropriate investigation. For information-only reports, victims should omit all personally identifiable information to ensure confidentiality.


Type and Basis of Complaint:

Type of complaint: Discrimination Harassment Retaliation

If you are filing a discrimination or harassment complaint, please indicate the protected status(es) that is/are the basis of the alleged behavior:

Race/Ethnicity
Nationality
Sex/Gender
Age
Marital Status
Sexual Orientation
Genetic Predisposition
Religion
Veteran Status
Disability


Respondent/Accused Information:

Please identify the person against whom your complaint is made.

Name:
Contact Information:
Is this person a: Student Employee Vendor Visitor or
Other (Please specify):
Title/Department (if applicable):
Relationship/Association to you:
Additional Respondent Information:


Complaint:

While providing details is essential to investigating your complaint, please be advised that some or all of the information you provide in this section may be shared with the person(s) you are accusing. You may supplement this description later if you wish to share additional details.

Describe the incident(s)/event(s) including dates, times, locations, and any potential witnesses to the behavior:

Describe the impact that the behavior has had on you:

Have you taken any action to stop the behavior? Yes No
If so, what actions have you taken and what was the outcome?

Please add below any information that supports your complaint:


Resolution:

What remedy are you seeking?

Thank you for your information. Adelphi University is committed to providing an environment which is free from harassment and is committed to investigating any and all allegations of harassment.

This form will be forwarded to the Office of Human Resources and investigated according to the processes delineated in the Anti-Harassment Policy. We recommend familiarizing yourself with this policy and process, which is available at http://www.adelphi.edu/hr/policies/harassment.php

In order to protect your anonymity, you will not receive an acknowledgement of this email and your email address will not be forwarded to the Office of Human Resources.

By submitting this form, I certify that the information I have provided is true and accurate to the best of my knowledge.


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Contact Us
For more information, please contact:

Office of Human Resources
p - 516.877.3220
f - 516.877.4970
e - humanres@adelphi.edu
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