COMPLAINT FORM FOR HUMAN RIGHTS VIOLATION - Download as PDF by undul849

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      COMPLAINT FORM FOR HUMAN RIGHTS VIOLATION                                                       1. Date complaint filed
                                   College of Saint Benedict                                          with human rights officer
                                                                                                      _______
                                    Saint John’s University                                           2. Date of service of
                                   Order of Saint Benedict                                            complaint on respondent
                                                                                                      ________
                                  SELF REPORT FORM                                                    3. Date of respondent
                                                                                                      response ________


1. Complainant:
   Name:
   Year in School:
   Address:
   Phone:

2. Respondent:
   Name:
   Year in School:
   Address:
   Phone:

3. Date of Report:                                                      Time:

4. Date of Violation:                                                   Time:

5. Location(s) of Incident(s):

6. Type of Discrimination or Harassment (check all that apply):

        a. Race/Color ____        c. Sex ____          e. Sexual Orientation ____       g. National Origin _____
        b. Disability ____        d. Age____           f. Religion ____                 h. Other ____

INFORMATION REGARDING THE COMPLAINANT

7. Relationship to the Institution:             8. Complainant lives:            9. Race/Ethnicity:
   a. Undergraduate                                a. On campus                     a. Asian
   b. Graduate                                     b. Off campus                    b. Black
   c. Prep                                                                          c. Hispanic/Latino
   d. Faculty                                                                       d. American Indian
   e. Staff                                                                         e. White
   f. Visitor                                                                       f. Mixed
   g. Other ___________________                                                     g. Other ___________________


INFORMATION REGARDING THE RESPONDENT(S)
                                                                   i.   Other:
10. Number of respondents: _____
                                                               12. Respondent(s) Live(s):
11. Race/Ethnicity of Respondent(s):                               a. On Campus
    a. Asian                                                       b. Off Campus
    b. Black                                                       c. Multiple offenders from different locations
    c. Hispanic/Latino                                             d. Unknown
    d. American Indian
    e. White                                                   13. Relationship to victim:
    f. Mixed                                                       a. Stranger
    g. Multiple Offenders of different race                        b. Acquaintance
    h. Unknown                                                     c. Classmate
    d. Date
    e. Partner/Lover                                                  15. Approximate ages of Respondents(s):
    f. Ex-partner/Ex-Lover                                                ____________
    g. Spouse
    h. Ex-spouse
    i. Faculty                                                        16. Relationship to Institution:
    j. Staff                                                              a. Undergraduate
    k. Supervisor                                                         b. Graduate
    l. Unknown                                                            c. Prep
    m. Other _______________                                              d. Faculty
                                                                          e. Staff
14. Was Respondent using:                                                 f. Visitor
    a. Drugs                                                              g. Multiple offenders of
    b. Alcohol                                                                different affiliation
    c. Unknown                                                            h. Unknown
                                                                          i. Other _______________

TO THE EXTENT POSSIBLE, THE IDENTITY OF THE COMPLAINANT WILL REMAIN CONFIDENTIAL.

RESPONSE/RESOURCES/SERVICES

9. Does the complainant plan                          e. Other _______________
   on taking action against the                                                                h. Campus Ministry
   respondent(s):                                 11. What resources/services has              i. Academic Advising
   a. Yes                                             the complainant been                     j. St. Cloud Hospital
   b. No                                              connected with at this time:             k. Local Law Enforcement
   c. Unknown at this time                               a. Human Rights Office                l. Sexual Assault Center
                                                         b. Security Department                m. Battered Women’s Shelter
10. If yes, circle all that apply:                       c. Student Development                n. Other _______________
    a. Internal complaint                                d. Residential Life
    b. Criminal complaint                                e. Counseling Center
    c. Civil suit                                        f. Health Center – SJU
    d. Unknown                                           g. Health Educators - CSB


     SIGNATURES:
     _______________________________________                          ____________________________________
     Complainant                                                      Human Rights Officer

     Date: __________________________________                         Date: ______________________________


  Office Use Only
  OUTCOMES:
  Complainant:
  Respondent:
  University:
  Criminal:
  Other:




  Office Use Only:
  Human Rights Case #__________ CSB Security Case #___________              SJU Life Safety Case # ___________

                  Please complete and return this form in a sealed envelope marked “Confidential” to:
                      BernaDette Wilson, Room 205, Mary Commons, CSB St. Joseph, MN 56374
                                       If you have questions call (320)363-5455.
M: Student Human Rights/HR Self Report 0604.doc
08/16/07

								
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