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Complaint Number
EMPLOYEE INTERNAL COMPLAINT INTAKE FORM
This complaint form is to be utilized for reporting conduct that is believed to be in violation of St. Mary's College of
Maryland's policies.
1. COMPLAINANT – Person who alleges the violation of St. Mary's
College of Maryland's policies:
Last Name
First Name
Primary Rol
e Faculty Staff Third Party
on Campus:
Other, please state:
Position / Title
School / Dept.
H
ome Address
City State Zip Code
Phone Number
Email
RESPONDENT – Person you believe to be responsible for the
alleged violation of St. Mary's College of Maryland's policies:
Last Name
First Name
Primary Role Faculty Student Third Party
on Campus:
Staff Other, please state:
Position / Title
School / Dept
.
Home Address
City State Zip Code
Phone Number
Email
2. BASIS OF YOUR COMPLAINT: What is the reason for your complaint? (Please check all applicable items.)
Age Ancestry Color Disability Gender Expression
Gender Identity Genetic Information Harassment Marital Status National Origin
Political Affiliation Pregnancy Race/Ethnicity Religion Reprisal/Retaliation
Sex Sexual Harassment Sexual Misconduct Sexual Orientation Title IX
Veteran Status Other, please state:
If you checked color, religion
or national origin, please specify:
If you checked genetic information, how did the Respondent obtain the genetic information:
What type of genetic information is involved: genetic testing family medical history genetic services
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