UAB Discrimination Complaint Form

My Relationship to UAB

Check One:
Faculty
Staff
Undergraduate Graduate Professional
Applicant
Other
If Other Please Explain:

Complainant Identification Information


Contact Information

Have you brought this matter to the attention of any other departments(s) within the university?
If Yes, please list the name(s) and departments(s) of all other persons with whom you have discussed this matter.
Have you brought this matter to the attention of any person or agency outside of the university?
If Yes, please list the name(s) or agencies(s) with whom you have discussed this matter.

Type of Complaint

Age
Genetic or family medical history
Sex
Color
National Origin
Disability unrelated to job performance
Race
Sexual Orientation
Gender Expression
Religion
Veteran Status
Gender Identity
Retaliation
Other
Sexual Gender Based Non Sexual
If Other Please Explain:

Complaint

Explain how you believe you were discriminated against (treated differently from other faculty, staff or students). Please summarize below and attach additional pages describing your compaint if necessary.
Name of person or persons you believe discriminated against you and the nature of the contact you have/had with them, e.g. supervisor, co-worker, faculty, customer, etc...
Describe the corrective action you are seeking. Attach additional pages if necessary.
For retaliation complaints, please explain why you believe someone retaliated against you.

Signature

Witnesses (The relationship information requested means co-worker, supervisor, customer, faculty, etc.)
I certify the aforementioned is true and accurate to the best of my knowledge or belief.

Your signature

Date
Complaint taken by

Your signature

Print Name

Date