JWCC Discrimination Complaint Form

This form must be used to describe alleged discrimination in violation of a John Wood Community College policy and/or a law. It is understood that any complaint is informal until this form has been completed. An investigator will be assigned by the John Wood Community College President.

Name Name First Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Email
What is your affiliation with JWCC?
What is your protected class?
Incident details

Please provide a description of your allegations including dates, events, and people involved.
Date Date / MM / DD YYYY
Location of incident
Name(s) of the individual(s) you believe discriminated against you:
Witness(es) to the incident(s) (if any)
Please provide a detailed description of the incident(s). Include as much information as possible, such as specific actions, reason(s) for claim of discrimination, statements, and any relevant context.
By signing below, I confirm and acknowledge that the information provided is true and accurate to the best of my knowledge and that by submitting this form an investigation will be initiated. I understand attempts will be made to keep this investigation confidential if I so request, but that the investigation may involve talking with co-workers, students, or other parties who may be knowledgeable about the alleged violation.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Today's Date Today's Date / MM / DD YYYY

JWCC Discrimination Complaint Form

JWCC Discrimination Complaint Form

Incident details