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Discrimination, Harassment and Retaliation Complaint Form

Instructions

This form should be completed in its entirety, and submitted to Human Resources in person at 262 South Main Street, Lodi, New Jersey 07644; via fax to (201) 559-6199. A form can be requested by calling (201) 559-6055 or at the Felician University Sharepoint site

If a faculty or staff member is notified of an allegation he/she must refer the alleger or notify Human Resources as soon as possible and no later than five days after becoming aware of the allegation.

Filing an allegation of discrimination or harassment with Felician University does not preclude an alleger from filing an allegation with an external agency, nor does it extend time limits for such complaints.

Person alleging discrimination/harassment:  ____________________
Name:  ____________________
Title:  ____________________
Department:  ____________________
Campus mail address:  ____________________
Campus phone:  ____________________
E-mail address: Person against whom allegation of discrimination/harassment is being made:  ____________________
Name:  ____________________
Title:  ____________________
Department:  ____________________
Campus mail address:  ____________________
Campus phone:  ____________________
E-mail address: Person referring the complaint (if different from person alleging discrimination/harassment):  ____________________
Using the space below and/or additional attachments, describe the events and/or behaviors that are the subject of the complaint. Include any offices or individuals you have spoken with on campus, the names of witnesses, as well as dates, times and locations.

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