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Equal Opportunity/Title IX Complaint Form
Reporting Person's Information
First Name
(Required)
Last Name
(Required)
Email
(Required)
CCC ID
Street Address
(Required)
City
(Required)
State
(Required)
Select
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Zip Code
(Required)
Telephone Number
(Required)
CCC Affiliation
(Required)
Select
Employee
Student
Employee and Student
Other
Other Affiliation
Incident Submission Information
Incident Date
(Required)
Department/Class
(Required)
Location
(Required)
Select
Arturo Velasquez Institute
Dawson Technical Institute
Harold Washington
Harry S Truman
Humboldt Park Vocational Educational Center
Kennedy-King
Malcolm X
Olive-Harvey
Richard J Daley
South Chicago Learning Center
West Side Learning Center
Wilbur Wright
Other
Other Location
Name of the individual I am filing this Equal Opportunity/Title IX Complaint against
(Required)
First Name
Last Name
Is the person that the complaint is being filed against an employee or a student?
(Required)
Select
Employee
Student
Other
Other
Provide the name(s) and telephone number(s) of any witness (es) to the incident
Witness #1 Name
Witness #1 Email
Witness #1 Type
Select
Employee
Student
Other
Witness #1 Type Other
Witness #1 Phone
Witness #2 Name
Witness #2 Email
Witness #2 Type
Select
Employee
Student
Other
Witness #2 Type Other
Witness #2 Phone
Basis of Discrimination or Harassment
check all selections that may apply
(Required)
Age
Citizenship
Dating/Domestic Violence
Disability
Ethnicity
Gender
Genetic Information
Marital Status
Membership or participation in an organization
National Origin
Pregnancy
Race
Religion
Retaliation
Sexual Assault
Sexual Harassment
Sexual Orientation
Stalking
Veteran Status
Other
If "Other" selected in the "Basis of Discrimination" question above enter reason below
Has an Incident Report been filed with a CCC Office of Safety and Security?
(Required)
Select
Yes
No
Incident Report Date
Has a police report been filed with the City of Chicago Police Department?
(Required)
Select
Yes
No
Police Report Date
Description of Incident
The fact(s) of the incident which lead me to believe I was discriminated against or harassed were as follows (attach supporting documents, images or other materials)
(Required)
Would you like to add supporting documents?
(Required)
Select
Yes
No
Attachments
Drop files here or
Select files
Max. file size: 1 MB, Max. files: 10.
Requested Remedy
Electronic Signature
(Required)
Enter Full Name
