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Conestoga
 
Complaint Form - Human Rights Harassment/ Descrimination Complaint
 
Complainant's Name *      

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Position      
         
         
Other      

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Respondent's Name      

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Address      

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Telephone (Business)   Telephone (Residence)  
   
         
Position      
         
         
Other      

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Department / Program Location      

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Section of the Policy that this complaint is being filed under    

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In your own words, please indicate the details of your complaint under the Human Rights Policy: If you would like to provide a more detailed description, please attach to this form. Provide copies of any documentation which may be relevant tothe issues of this complaint. List the documents provided.

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Please describe any actions that you have taken to try to resolve this matter.

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This document and any attachments to it that you provide in the course of filing a complaint will be held in confidence by the College. Page one of this complaint form and its attachments will be disclosed to the respondent named in the complaint and to the investigator, adjudicators and mediators appointed to assist with the resolution of this complaint, as outlined in the policy procedures. Privileged information, such as the complainant s requirements to resolve the complaint and list of witnesses,provided on page two of this complaint form, will not be disclosed to the respondent. Your signature confirms that you have been made aware of and give permission for the above use of this information.
         
Signature of complainant   Date  
 
Select a date from the calendar.
 
         
         
Complainant Information
         
         
Name *      

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Address      

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Telephone (Business)   Telephone (Residence)  
   
         
Email      

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Department & Location      

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Name of respondent      
         

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What do you require to resolve this complaint?

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Witnesses to the events of this complaint : Please identify , in order of importance , anyone that you feel would provide helpful information to assist the investigation of this complaint.
         
         
Name   Telephone  
   
         
Name   Telephone  
   
         
Name   Telephone  
   
         
Name   Telephone  
   
         
Signature of Complainant   Date  
 
Select a date from the calendar.
 
         
Complaint received by   Date  
 
Select a date from the calendar.
 
         
Information gathered under this policy may be required to be disclosed under the Ontario Human Rights Code or other legal proceedings.