Preventing and Addressing Discrimination, Harassment, and Retaliation Complaint Form

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The University of Virginia Office for Equal Opportunity and Civil Rights (“EOCR”) administers the University’s policies on Preventing and Addressing Discrimination and Harassment (“PADH Policy”) and Preventing and Addressing Retaliation (“PAR Policy”), available here:

This Complaint Form is designed to gather the necessary information for EOCR to determine whether your complaint states a potential violation of the PADH Policy and/or PAR Policy. Therefore, please answer each question as thoroughly and accurately as possible. If you need assistance completing the form, please contact EOCR at (434) 924-3200 or and request to speak with the Compliance Director for EOCR.

We realize that this process may cause stress or anxiety. There are confidential resources available at the University. Please visit EOCR’s website for more information:

Please note that complaints of sexual assault, sexual exploitation, intimate partner violence, stalking, sexual harassment, and harassment based on gender, sexual orientation, gender identity, or gender expression are covered by a separate University policy, Policy on Sexual and Gender Based Harassment and Other Forms of Interpersonal Violence, and procedures. For more information, please contact the University’s Title IX Office at (434) 297-7988 or, or visit:

Basis of Complaint

Please select the protected characteristics/statuses that you believe are the basis for the discrimination and/or harassment. For example, if you believe that you were treated less favorably than someone else because of race, you should check the box next to Race. If you believe you were treated less favorably for several reasons, such as your age, disability, and religion, you should check all that apply. Please check the Retaliation box if you believe you were treated adversely because you: complained about discrimination or harassment in violation of the PADH Policy or retaliation in violation of the PAR Policy; participated in a University process to resolve a discrimination, harassment, or retaliation complaint; or you filed a complaint or charge of discrimination.

Incident Details

Please describe the action(s) taken against you or the unwelcome conduct that you believe was discriminatory, harassing, or retaliatory.

Similar or Same Situation or Treatment

For example, who else applied for the same job you did, who else violated the same policy, or who else had the same performance? Provide the protected characteristic of these individuals, if known, and if it relates to your claim of discrimination. For example, if your complaint alleges race discrimination, provide the race of each individual; if it alleges sex discrimination, provide the sex of each individual; and so on.

Of the individuals in the same or similar situation as you, who was treated more favorably than you?

Of the individuals in the same or similar situation as you, who was treated less favorably than you?

Of the individuals in the same or similar situation as you, who was treated the same as you?


Would you prefer informal resolution, negotiated resolution, or formal resolution (an investigation)? Please note that depending upon circumstances, EOCR may not be able to honor your preference.

Formal Resolution:

Formal resolution is an investigation conducted by a trained EOCR investigator, whose role is to conduct a thorough, fair, and impartial investigation.

Investigation Overview: During the investigation, the parties will have an equal opportunity to be heard, to submit information and corroborating evidence, to identify witnesses who may have relevant information, and to submit questions that they believe should be directed by the Investigator to each other or to any witness. The Investigator will notify and seek to meet separately with the Complainant, the Respondent, and third-party witnesses, and will gather other relevant and available evidence and information, including electronic or other records of communications between the parties or witnesses (via voice-mail, text message, email and social media sites), photographs (including those stored on computers and smartphones), and medical records (subject to the consent of the applicable party). The investigation conducted by EOCR may further include, but is not limited to:

  • interviewing material witnesses;
  • reviewing relevant files and records;
  • comparing the treatment of the Complainant to that of others similarly situated in the department or unit;
  • reviewing applicable policies and procedures; and/or
  • following-up with the parties as new evidence is collected, as appropriate, and permitting the parties to provide additional information to the record.

Timeframe for Investigation: The timeframe for completion of the investigation is sixty (60) calendar days from the date of notice to the parties of commencement of investigation. This timeframe may be extended for good cause which may exist if additional time is necessary, for example, to comply with a request by external law enforcement for temporary delay to gather evidence for a criminal investigation, to accommodate the availability of witnesses, to account for University breaks or vacations, to account for complexities of a case, including the number of witnesses and volume of information provided by the parties, or for other legitimate reasons. EOCR will notify the parties in writing of any extension of this timeframe.

Informal Resolution:

Certain types of discriminatory and/or harassing conduct or retaliatory conduct or concerning behaviors that may not yet rise to the level of prohibited conduct may be more appropriately and efficiently resolved through a form of informal resolution outlined below. On the other hand, some reports of prohibited discriminatory, harassing and/or retaliatory conduct, particularly those implicating violence or particularly severe harassment, may not be appropriate for informal resolution and the University reserves the right to proceed with formal resolution at any time.

Pursuing resolution under the Informal Procedures does not preclude subsequent recourse to the Formal Procedures if the attempts at informal resolution fail to adequately resolve the reported concern. You are not required to follow the Informal Procedures before initiating Formal Procedures.

Informal Procedures may involve individual and/or community remedies that are designed to address a report of prohibited discriminatory, harassing and/or retaliatory conduct, such as:

  • Resolution with the Assistance of a Third Party: This option involves EOCR assisting or coordinating a meeting between Complainant, Respondent, and a third-party neutral facilitator, or EOCR providing information to Complainant about options for seeking assistance in informally resolving a report from other University resources.
  • Interventions and Remedies: Resolution under Informal Procedures may also include other interventions and remedies, such as broad-based educational programming or training for relevant individuals or groups; one or more sanctions for the Respondent(s), if warranted and in accordance with relevant disciplinary procedures; and/or any other remedial or protective measures that can be tailored to the involved individuals to achieve the goals of the PADH and PAR Policies.

Any combination of the options offered under the Informal Procedures may be utilized in any order. If resolution of the report of Prohibited Discriminatory and/or Harassing Conduct or Prohibited Retaliatory Conduct is reached through one of these Informal Procedures, the matter will be considered closed. If resolution is not reached, and EOCR determines that further action is necessary, or if a Respondent fails to comply with the terms of any agreed to resolution, the matter will be referred for investigation under the Formal Procedures.

Negotiated Resolution:

Negotiated resolution is a process by which EOCR attempts to resolve complaints that allege potential conduct that may violate the PADH Policy and/or PAR Policy quickly and to the satisfaction of all parties without reaching formal findings, while protecting confidentiality to the extent possible.

  • If EOCR determines that negotiated resolution is appropriate, EOCR will notify the Respondent that the Respondent has been named in a complaint and advise the Respondent of the nature of the allegations. Such notification will provide information regarding PADHR Complaint Procedures and will offer the negotiated resolution option to the Respondent, who has five (5) business days from receipt of this notice to decide whether to exercise this option. Negotiated resolution will normally be completed within thirty (30) calendar days from the date the Respondent agrees to this process, absent extenuating circumstances.
  • If EOCR deems the complaint unsuitable for negotiated resolution or if either party declines to participate in or fails to make a decision regarding negotiated resolution, EOCR will conduct an investigation in accordance with the PADHR Complaint Procedures.
  • At any time during the negotiated resolution process, either party may elect to terminate the process. Upon termination of the process, EOCR will investigate the complaint in accordance with the PADHR Complaint Procedures. EOCR reserves the right not to proceed with an investigation if, during negotiated resolution, the Complainant was offered and refused all of the relief to which the Complainant would be entitled if a formal investigation was conducted.
  • Generally, EOCR will only involve the Complainant, the Respondent and individuals necessary to facilitating the negotiated resolution process. Likewise, the parties will be asked to respect the confidentiality of the process. In some cases, it may be necessary to consult with or otherwise involve other University officials regarding University policies and procedures or available remedies. However, information will be provided solely to these individuals on a need-to-know basis.
  • If the complaint is successfully resolved, the parties will sign a “Negotiated Resolution Form” prepared by EOCR, setting forth the agreed-upon terms. Upon the parties’ execution of the Negotiated Resolution Form, EOCR will destroy all other documents and notes except the original complaint. Copies of the complaint and the Negotiated Resolution Form will be provided to the Complainant and Respondent upon request and maintained by EOCR in accordance with University policies and state and federal law.


By completing and submitting this form, I understand that I am initiating a complaint for which I request that the University of Virginia Office for Equal Opportunity and Civil Rights conduct resolution under the PADHR Complaint Procedures. I certify that the information I have provided is true and accurate to the best of my knowledge.

Supporting Documentation

Once you have submitted this form, you will have an opportunity to upload any supporting documentation (e.g., copies or screenshots of documents, emails, photos, text messages, and/or other evidence related to this report) you may have.