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Salt Lake Community College

Office of Equal Employment Opportunity (EEO)


Discrimination Intake Form - Student

Office of EEO

801-957-4561

First Name:
Last Name:
S Number:
Preferred Pronouns:
Address:
City:
State:
Zip Code:
Department:
Position:
Title:
Work Phone:
Preferred Email Address:
Home / Cell Phone:
What SLCC Campus(es) did this incident occur?:
* This is a Discrimination/Harassment Complaint. (Please refer to SLCC Policy Chapter 2, 1.11; 1.12.) Nature of complaint - please check applicable issue(s):


* Name or Description of Responding Party (person you are making the complaint about):
Responding Party Contact Information:
(If there is more than one Responding Party, please use the following lines to give their information.)
* Please provide a brief description of the event(s) that led to this complaint:
(Please attach a file containing a detailed description. Use names, places, and/or dates when possible.)

Name of Witness(s): Please list anyone who was present during the incident or may have information.

Name:
Phone Number:
Name:
Phone Number:

Please attach any relevant supporting document(s) including the detailed description:

List any persons employed at SLCC with whom you have spoken regarding the incident(s):
If you have tried to resolve this with an Associate Dean, please explain the results:

I have read and understand the following:

  1. I affirm I have given the above information in good faith and it is true to the best of my knowledge.
  2. I understand at any time I have the right to file a complaint with an outside state/federal agency, Equal Employment Opportunity Commission, Utah Anti-Discrimination and Labor Division, or pursue a remedy in a Court of Law.
  3. I understand the EEO Department is not an advocate for either party. The EEO Department adheres to the processes prescribed in this policy, investigates when necessary, and safeguards the rights and due process of those involved.
  4. The SLCC EEO Department, (801) 957-4561, will assist you if you have questions or concerns about the process or your employment rights.
  5. I understand all official communication will be through Bruin Mail or SLCC Mail. It is my responsibility to check Bruin Mail and SLCC Mail for updates on this case.

Date: 1/23/2022

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Salt Lake Community College

4600 South Redwood Road Salt Lake City, UT 84123
801-957-7522
Student Services hours: M - F : 7am -7pm
Enrollment Info: 801-957-4073 | contact@slcc.edu