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Home Student Life Diversity and Inclusion at the CVM Diversity and Inclusion : Anonymous Feedback

Diversity and Inclusion : Anonymous Feedback

Diversity and Inclusion at the CVM

Diversity and Inclusion : Anonymous Feedback

If you have an emergency, please call 911.

The UGA College of Veterinary Medicine is a community where diversity and inclusion are valued. If you've experienced or witnessed an event at the college that you feel violates our stand on diversity and inclusion, you are encouraged to report it below.
Reporting Party
Reporting Party:
First Last
Reporting Party Title:
Reporting Party is the alleged victim:*
- Yes
- No
Department:
Contact Phone Number:
UGA Email Address:
Status:
- Student
- Faculty
- Staff
Request Confidentiality:*
- Yes
- No
Basis of Complaint
Basis of Complaint (Check all that apply.)
- Age
- Ethnicity
- Religion
- Disability
- Sexual Oriantation
- Race
- Gender Identity
- Retaliation for previous complaint/investigation
- Sex/Gender
- Other
If Other - Please List:
Respondent (person alleged to have violated the CVM's policy)
Respondent Name:*
First Last
Respondent Title (if applicable):
Department:
Contact Phone Number:
UGA Email Address:
Status:
- Student
- Faculty
- Staff
Details of Complaint
Date of Incident
Date Format: MM slash DD slash YYYY

Choose a date.
Time of Incident

: Hour

Minutes
Location of Incident
Clarifying Location Information if Needed
A) Describe incident of discrimination or retaliation.*
Describe incident of discrimination or retaliation. Please be as detailed as possible, giving names, date, and place of incident.
B) Witnesses*
List those witnesses you believe have information about your complaint. Include complete information for each witness listed. If the Reporting Party is not the alleged victim, please identify the alleged victim as a witness. If no witnesses, enter N/A.
Additional Information
Previous Report?*
A) Have you previously reported or otherwise complained about this or related acts of harassment, discrimination or retaliation to a CVM supervisor or official? If so, please identify the individual to whom you made the report, the date you made the report, and the resolution. If not, enter N/A.
Resolution:
What would resolve this complaint?

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