El INFORMAL Prewcomplaint counseling/ guidance/ informal resolution with Department .8 LEVEL ONE Formal EOAA Investigation LEVEL TWO - Appeal to Level 1 Investigation 4 IKENT STATE UNIVERSITY EQUAL OPPORTUNITY AND AFFIRMATIVE ACTION COMPLAINT FORM Please print legibly NAME: (Last Name) 1175 ame TITLE: 5mm 4- BANNER ID: DEPARTMENT: 0F mum: CAMPUS LOCATION: d?nw?fp/ Mfg/mm} Afrf HOME ADDRESS, 8: ZIP: OFFICE PHONE NUMBER: HOME PHONE STATUS AT THE UNIVERSITY (Place an in the appropriate box.) Student l_l Classi?ed Unclassi?ed Faculty (A Current Terminated Ll Applicant for Employment Employee Employee PROTECTED CLASS (Place an in the appropriate box(es) which indicates the basis of your alleged discrimination) Age (40 yrs. old or older) Race Disabled Veteran NIiJitary Status National Origin Religion. Disability Vietnam Era Veteran Gender Color Sexual Orientation El Sexual Harassment Genetic Information (GINA) ALLEGED DISCRIMINATORY ACTION AREA (Place an in the appropriate box(es) which best identify the area(s) which you perceive are applicable to your complaint.) Recruitment Retaliation Hostile Environment Disciplinary Action I: Termination El Training Terms 8.: Conditions Harassment I: Pay Personnel Evaluation Promotion/Demotion Failure to Accommodate Other (Please describe in the Space provided below) Page 1 of 3 DESCRIPTION OF THE ALLEGED DISCRIMINATORY Please use the following space to describe the discriminatory action which occurred. Be as precise as possible with regard to the names and titles positions of the involved participants, names of Witnesses, locations, times, and dates. Use an additional sheet of paper if necessary. Who was involved (name title/Offensive or discriminatory act that occurred?(Use additional plain papel if necessary) He Ma/nfm m9 M?f/h 13.941? 1: WM or! Maw/am (1&1:ch 242? 5 Lewd 1.074417%? p591 Wild-V10 4+ Mm 4' A is gem/1/1291 He deg/WM mt"! thin ndhf?d a ?and WA 4+ 2447 A. +1a+ Baa 11/5ng mama/5 mop/e Cant! 0.541115?) a5 f/?mJ? Wivw? Wm. Ma?a/e if A 11/1! 1? km ?na?g/ "(he ,1 which ?rm! was Ital?12' 311174;. pane/m, 1: Perl 140+ - . . -- . 1.417149% 19/, or! ?ne Mn 0.6 MA 2014.1 5mm W11 1H- [2101111, ?00 Pm TM lei/1+ cm! W512 A115 5441! CRACK-.979 peep/r it? our 56.1% 41/6311}! :3 09M was 535% and my a ?ap/v v1.9 race 15:1. {vim 50 fail/U10 as; #gy MM 44? $10 ?We! 455w]? clam; om mw? Jimmf. awn} miter/1y mtg/A? 5m? em Mar/51}: i knew .67/ 1,515+ 411154.141! Africa-M Aa? Janmr?tf! 1 5/1714 We +42% 5? 52:19:16 gym? 735*? ?If. When did 1thappen (date, rrecurring 0/175? Pym?M61!? 4313?]? m'yn?y?? and 13?. 46 am M- mam. 13;.9914? a/Wnd 10?? Pm Where did it happen (location, bldg., room 51%ng How didyou react/respond? I ?0 @0544}?! . I . \X?ere there any Witnesses? Yes No Ifyou answered please indicate the name(s) of the \vitness(es): 5fl/og?5 bdf'h S?ll?l {Mona ?((0141-15- Did you tell anyone about this? (Supervisor, Dean, Instructor, Student Ombuds or De artment Chair) Yes If you answered ?Yes? please indicate the name(s) of those you told: m?h 14161 ~MPa/M1en+ Clinic ?/v?sle/ Do you have any physical evidence emails, photos, letters, documents, text messages, Facebook/ Twitter posts, etc.) of this claim? Yes No If so, please provide any copies to the Of?ce Equal Opportunity Affirma?ve Action (EOAA) 635 Loop Rd, Hear Hall, Kent OH 44242. 0001 Page 2 of 3 Has your jg?< or student status been affected in any way as a result of this alleged incident and if so, please describe the affect below. Yes NO '13 Real rim!? Igy In; VIA 4w Par/5 a my ?mm Ms 5m Agn?ag far/avg: 1" 4? i 53/} CWW awr- wAar? 01251.? Lgyl/J ?4n Ja AWE Gas/mil . W?hat proposed resolution and/or remedial action are you seeking: 0/1 73;!9 (gift/[J If? Mac/my; lag/1+ ?are Jug for ?lm/J5 sway/12?s. MW 0:5 Ag/ MHWS and MB away/Hm ?rd/243w. wu? a. While the Equal Opportunity and Af?rmative Action Of?ce uses its best efforts to protect information you provide from disclosure, such information is subject to release under the following circumstances: request for public records, in response to charges ?led with the Equal Employment Opportunity Commission (EEOC), the Ohio Civil Rights Commission (OCRC), Department of Education (DOE), Civil Rights section and other administrative agencies or complaints ?led in state or federal court, whether ?led by you or others. I have read and understand the contents of this document. All statements and responses are accurate to the best of my knowledge and I declare that this complaint has been made in 1th. - COMPLAINANT SIGNATURE ACKNOWLEDGED BY COMPLIANCE COORDINATOR DATE DATE 3?24 59 (AuthoriZed signature required for processing by Of?ce of EOAA) Page 3 of 3 INFORMAL - Pre?complaint counseling/ guidance/ informal resolution with Department LEVEL ONE - Formal EOAA Investigation El LEVEL TWO - Appeal to Level 1 Investigation KENT STATE UNIVERSITY EQUAL OPPORTUNITY AND AFFIRMATIVE ACTION COMPLAINT FORM Please print legibly NAME: ll?St ame TITLE: BANNER DEPARTMENT: Swot 03} MOSES CAMPUS LOCATION: HOME ADDRESS, ZIP: OFFICE PHONE NUMBER: HOME PHONE NUMBER STATUS AT THE UNIVERSITY (Place an in the appropriate box.) Student Classi?ed I: Unclassi?ed Faculty Current Terminated I: Applicant for Employment Employee Employee PROTECTED CLASS (Place an in the appropriate box(es) which indicates the basis of your alleged discrimination) [3 Age (40 yrs. old or older) I: Race [3 Disabled Veteran Military Status National Origin Religion Disability Vietnam Era Veteran Gender Color Sexual Orientation Sexual Harassment Genetic Information (GINA) ALLEGED DISCRIMINATORY ACTION AREA (Place an in the appropriate box(es) which best identify the area(s) which you perceive are applicable to your complaint.) I: Recruitment [El/Retaliation Hostile Environment [3 Disciplinary Action Termination Training Terms Conditions I: Harassment El Pay Personnel Evaluation El Promotion/Demotion [3 Failure to Accommodate Other (Please describe in the space provided below) DESCRIPTION OF THE ALLEGED DISCRIMINATORY Please use the following space to describe the discriminatory action 1which occurred. Be as precise as possible with regard to the names and titles/ positions of the involved participants, names of witnesses, locations, times, and dates. Use an additional sheet of paper if necessary. Who was involved (name 8.: title/Offeiisive or discriminators aCt that occurredFUJse additional plain paper it'lnecessarr) Dr, .irsse issue is we 1me Ste-tr. arrest JP Email-1R if! the ere-:2: or Was-{Cs Fri/?1 Will on iW:Lf?th_ 11, a mam? Me one on 1% lm: allmeal 11-1; e. an 'Thui'SL so _i arch ii mews __som it Li _me a pear Jae his. Eleni some .1 rural/n use so new?, we: a were: 0.;an L?ilHr-l? Jain- "il'l?in a sir-rich "was-n ire-13? ism" 4m 11?:qu woman capo-as -?tl?1r?ah? is a jrriir start and a pm? mm, on tri?e-rites, Marsh Mar-ii? marl ii'i sorori?fsmr eti- v; . . New on "rinses" of Mid?? Wanna 10971 on ?summer, mini/ch la, The os-s'r 5am, m2 ream Starr 5354mm at lie-3% Esme seamen ?pm-91cm it. llp'.? .sniliiq {Mic-rag" Is rinse-i rs be. 4% mi. 'Tl?u't. i?l'?lig 4 single. wl'l? ?in?li him home Jim? Sr} {of UP ?Id {133 We! (gamer mil-"Isl i118, sun iDL?ldi-S nlt?s?i error-Will if} lit-e serum assault zooming er: {hf Olivia/5"? because. When did it happen (date, one?time occurrence or recurring)? 1in Hill"? if. i 2? . 2 1?47, Where did it happen (location, bldg., roeni ii)? (1U 5'55 {3 lat; will Julfl orient-ails it six-re timer T?iol?sre? in ill-"tune, hum mum to {tor-4?73? Hm? 90313 mar Tlr. Letitia How did you Jud? milk 13(? i mini 4o Di"; Di?S?Sicr?, rVii-"ere there any witnesses? x/ Yes NO IFYOU answered ?Yes?, Please indicate then: Alibi l?il?cli?i?lm i'ii? Leash as ?which LLB Did you tell anyone about this? (Supervisor, Dean, Instructor, Student Ombuds or Department Chair) Yes No If you answered ?Yes?, lease indicate the name(s) of those you told: Ui?g?i? trans? Cl?l?i-t' 'Pfii'i ir alas can irr'i T. Do you have in: physical evidence (Le. emails, photos, letters, documents, text messages, Facebook/l?witter posts, etc.) of this claim? Yes No If so, please provide any copies to the Of?ce Equal Opportunity A?irrnative Action (EOAA) 635 Loop Rd, Heer Hall, Kent OH 44242?0001. Des MWM 'Di?smmi?nmw Momm CMWUM WM ma} mc?mmw Mam saw; mm, Mum I mew ?Shim (imam Ms (mm: Miami} aw? +0101 5 39mm Mam MCMM rm" Has your lob or student status been affected in any way as a result of this alleged incident and if so, please describe the affect below. 32 Yes No 1 am nirafdi?c WW 0mm SW51 in Mild (5L8 29: 8 can; 06/4 43mm LY/lic?i?m (LP 011w amt) am ?1 Lilian/Lari m1 Gian/71+ 3mm 01% mime wit/um mm m3 mm What propose: resolutionuand/or remedial action are you seeking: W?lilfi rf?f .1 0i .. ?wards am ?it-iiof??i Milt Lw?? mt 'W/mn?m/Ii . that 311% (:91de shawl b1 iV\\iOl lLbel I Lamp .0th .iesse; +0 be his ?Win-Liar?) fer ?rm 8690M (ii/113 Valet at int-Ind for -W twat 81mg Balms! at? WNW .. H- 0 While the Equal Opportunity and Af?rmative Action Of?ce uses its best efforts to protect information you provide from disclosure, such information is subiect to release under the following circumstances: request for public records, in response to charges filed with the Equal Employment Opportunity Commission (EEOC), the Ohio Civil Rights Commission (OCRC), Department of Education (DOE), Civil Rights section and other administrative agencies or complaints ?led in state or federal court, Whether filed by you or others. I have read and understand the contents of this document. All statements and responses are accurate to the best of my knowledge and I declare that this complaint has been made in good faith. ACKNOWLEDGED BY COMPLIANCE DIRECT EOAA COORDINATOR DATE f4}? Z?j/i?iil DATE (Authorized signature required for processing by Of?ce of EOAA) INFORMAL - Pre?complaint counseling/ guidance/ informal resolution with Department LEVEL ONE Formal EOAA Investigation LEVEL TWO - Appeal to Level 1 Investigation KENT STATE UNIVERSITY EQUAL OPPORTUNITYANI) AFFIRMATIVE ACTION COMPLAINT FORM Please print legibly NAME: . Irst. ame) TITLE: BANNER ID: DEPARTMENT: CAMPUS LOCATION: HOME ADDRESS, a: ZIP: OFFICE PHONE NUMBER: HOME PHONE NUMBER: - CELL PHONE NUMBER STATUS AT THE UNIVERSITY (Place an in the appropriate box.) VB Student I: Classi?ed Unclassi?ed I: Faculty Current I: Terminated Applicant for Employment Employee Employee PROTECTED CLASS (Place an in the appropriate box(es) which indicates the basis of your alleged discrimination) Age (40 yrs. old or older) Race Disabled Veteran lVIilitary Status El National Origin Religion Disability I: Vietnam Era Veteran I: Gender Color Sexual Orientation Sexual Harassment I: Genetic Information (GINA) ALLEGED DISCRIMINATORY ACTION AREA (Place an in the appropriate box(es) which best identify the area(s) which you perceive are applicable to your complaint.) '3 Recruitment MRetaliation El Hostile Environment El Disciplinary Action 1: Termination Training Terms 8: Conditions I: Harassment Pay El Personnel Evaluation Promotion/Demotion Failure to Accommodate Other (Please describe in the space provided below) Page 1 of 3 DESCRIPTION OF THE ALLEGED DISCRJMINATORY ACTION(S): Ple as e use rhc followin,g space to describe the discriminatory action wh ich occurred. Be as precise as possible with regard to rhe names and titles/positions of the involved participants, names l)f witnesses, locations, times, and dates. Use an ad dition al sheet of paper if necessary. Who was i nvolved (name & title/Offensive or discriminatory acr that occurred?(Use additional plain paper if necessary)_ Duec.fuc of Ha.eds , �de.. ) i½Sfa..g ra.m p:ish 1li�� /"o.n.,h n.�, �+ ,\n.,t- \O: -ao �- \X here did 1t happen (l•Jcation, bldg., rooro ff)? -'0"-L.!n._.___,,J:s::..1...... nS...._.,\-n.._,__""� "J'-'�.;.L.---------------- Wcrethcrcanywimcsscs? _K.__ Yes ___ .No lf y-ou answered •·y cs", please indicate the name(s) of the witness(es): tb3 �M 4'.oUo M";.($. Did you tell anyone about trus? (Supervisor, Dean, lnstructor, Student Ombuds or Department Chair) )t_ Yes_ No If you answered ''Yes", please indicate the narne(s) of those you told: -...----..----- =----=-----=---.---.--� ��J �e�;v,t�fbp;!'\:;;,,�� £piih�$1£ o� he.- k@ Do you havl' any phr:1cal cVIdencc (i.e. cmml.s,photos, letters. documents, text messages, Facebuok/1\11ttcc posts, etc.) of thlS claim? )C Yes ___ No lf so, please provide any copies w the ( )fficc Etual Oppurtunit}' 1\ffirmat.1vc Action (T,0/1.A) 635 Lem 1 Rd .. I leer I!all. Ken t>I I 44242-fl(l() I. Page 2 of3 Has your or student status been affected in any way as a result of this alleged incident and if so, please describe the affect below. Yes No if ?fg?s m; to be. Dr- Lewi?s - What proposed resolution and/ or remedial action are you seeking: As ma Dr. Wasp/m. +0 +?aph a?l- Hm}? Slate 0mm. +0 30 +0 ei-udpmf continual". 2 CD rt While the Equal Opportunity and Affinnative Action Of?ce uses its best e?orts to protect information you provide from disclosure, such information is subject to release under the following circumstances: request for public records, in respimse to charges ?led with the Equal Employment Opportunity Commission (EEOC), the Ohio Civil Rights Commission (OCRC), Department of Education (DOE), Civil Rights section and other administrative agencies or complaints ?led in state or federal court, whether ?led by you or others. I have read and understand the contents of this document. All ents and responses are accurate to the best of my knowledge and I declare that this complaint has been made .th. COORDINATOR DATE Hal DATE (Authorized signature required for processing by Office of EOAA) Page 3 of 3 DESCRIPTION OF THE ALLEGED PleaSe use the following space to describe the (?scriminatog; action which occurred. Be as precise as possible with regard to the names and titles/' positions of the involved participants, names ofwitneSSes, locations, times, and dates. Use an additional sheet ofpsper if necessary. Who was involved (name 6: title/Offensive or discriminatory act that occurredeUse additional plain paper if necessary) When did it happen (date, one?time occurrence or recording Where did it happen {locating bldg., room How did you react respond? Were there any witnesses? Yes No If you answered ?Yes?, please indicate the n2me(s) of the witnessfes): Did you tell anyone about this? (Supervisor, Dean, Instructor, Student. Ombuds or Department Chair) Yes No If yen answered ?Yes?, please indicate. the name(s) of those you told: Do you have any physical evidence Ge emails, photos, letters, documents, text messages, Facebookfl?witter posts, etc.) of this claim? Yes No If so, please provide any Copies to the Of?ce Equal Opportunity Af?rmative Action (BUM) 635 Loop Rd? Heer Hall, Kent OH 44242?0001. Page 2 of 3 Has youiL .1 . in, .-.. unm. .. .- IILV :fwl__ T. 1; 140;-? I 7? 1 Mu 1:1. to filzi with the Equei Empioyment Opportunity Commission (EEOC), the Ohio Civil? mt, 1-1. 1? oz?; 53 -1 Lo.? - - n: -- A: 151"qu -..- Civil Rights section and other administrative agencies or Am: 21:. :v u, whether ?ied by you or others I have teat}, and understand the contests of this document. Ail statements and responses are accurate to the best of my knowledge and I declare that this complaint has been made in good faith. COMPLAINANT SEGNATURE ACIWOWLEDGED BY COMPLIANCE DIRECTOR EOAA COORDINATOR DATE DATE (Authorized Signature required for processing by Of?ce of EOAA) Page 3 of 3