Discrimination and Harassment Complaint Form

YOUR NAME

If you report anonymously, our department will be limited to what we can do regarding your complaint.

YOUR EMAIL ADDRESS

YOUR PHONE NUMBER

PREFERRED METHOD OF CONTACT

Phone
Email

YOUR AFFILIATION WITH BOISE STATE *

Required

Faculty
Staff
Student

YOU ARE MAKING THIS REPORT *

Required

On your behalf
On someone else’s behalf

DATE OF INCIDENT OF CONCERN

DETAILS OF INCIDENT *

Required
Please include as much detail as you can, including a description of what happened, the names of the parties involved and their affiliation to Boise State (if known), and the location of the incident.

DO YOU BELIEVE THAT THIS INCIDENT WAS PROMPTED BECAUSE OF A PROTECTED CLASS?

If yes, please check all characteristics that apply:

Age
National Origin
Sexual Orientation
Creed/Religion
Race/Ethnicity
Veterans Status
Disability
Pregnancy
Sex/Gender

Please describe why you think the incident was prompted because of a protected class.

APPROXIMATE AGE OF PERSON WHO EXPERIENCED THE BEHAVIOR DESCRIBED ABOVE *

Required
(this will be used to determine if a mandatory report needs to be made per Idaho Code Section 16-1605 and Boise State Policy

OTHER PEOPLE OR PLACES THAT KNOW ABOUT THIS INCIDENT:

Office of the Dean of Students
Human Resources
Faculty member or Department
Residence Life Staff Member
Counseling Center/Health Services
Gender Equity Center
Athletic Department Staff or Volunteer
Other

If Other, please describe

Please attach any relevant files (i.e. emails, text messages, social media posts, etc.) that pertain to this complaint

Drop files here or

Max. file size: 10 MB.

PURPOSE OF REPORT *

Required
Please let us know what you would like to happen as a result of this report
NOTE: Boise State reserves the authority to determine the appropriate response to any report of misconduct affecting members of the university committee.

By submitting this form you indicate you understand that:

If you provide your name you may be contacted by Boise State Universities Office of Institutional Compliance and Ethics or designee to confirm receipt of the report and to determine if you need further information or assistance.
Information provided in this form will be used to assist Boise State to accurately report the number of incidents occurring on Boise State owned and controlled areas for the purposes of the annual security report and daily crime log compiled in compliance with the Clery Act (neither the annual security report or the daily crime log include any personally identifiable information).

Optional: If you would like a copy of this form emailed to you, please enter your email address here

You can also print a copy of this form by clicking on the PRINT button at the top right of this page.

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Discrimination and Harassment Complaint Form

Office of Institutional Compliance and Ethics