Contact Information
Note: You
may make an anonymous complaint, but OEO will be limited in the
follow-up that can be done on a complaint that is filed anonymously. To
make an anonymous complaint, please print this form instead of
submitting it online and mail or fax it to the Office for Equal
Opportunity at the address at the bottom of this form.
Last Name:
First Name:
Email:
Phone:
Please indicate your affiliation
EPA
Administrator EPA
Faculty EPA Professional NCSU Graduate Student NCSU Undergraduate Student SPA
Staff Other:
(Please describe.)
Major (if student) or Unit/Department:
Campus Box (if applicable):
Mailing Address (if no campus box):
City:
State:
Zip:
Complaint Information
Please provide the following
information about the person engaging in the alleged behavior. If you
do not have some if this information, please leave the item(s) blank.
Last Name:
First Name:
Email:
Phone:
Campus Box:
Mailing Address:
City:
State:
Zip:
Your Relationship with the Alleged Harasser
Date Behavior Started:
Date Behavior Ended:
Description of Alleged Harassment or
Discrimination:
Check the category (or categories) that
best describes the type of harassment you feel you are experiencing
(e.g., you feel you are being harassed based on your race or your
religion, etc.):
Race Color National
Origin Religion Creed Sex Age Veteran
Status Disability Sexual
Orientation Retaliation Other:
(Please describe.)
Submit Your Complaint
If you wish to submit your complaint
anonymously, please print it and fax or mail it to:
Amy Circosta
Fax: 919-513-1428
Forms submitted by
using the Submit Complaint button below may not be anonymous.
Updated on February 1,
2006 by EMS
