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If you are considering a report of discrimination or harassment and would like to be contacted, please fill out this form.
Your Report of Discrimination
Describe the situation or treatment about which you are concerned. Please include specific incidents to the best of your recollection, and include approximate date(s) if possible.
The details of your report, including any appropriate circumstances or supplementary information that may aid in resolving it.
Are you concerned that this situation or treatment was the result of one or more of the following?
Are you concerned that this situation or treatment was the result of one or more of the following?
Age
Criminal Conviction
Disability
Domestic Violence Victim Status
Familial Status
Gender Identity or Expression
Marital Status
Military/Veteran Status
National Origin
Predisposing Genetic Characteristics
Pregnancy
Race/Color
Religion
Reproductive Healthcare Choices
Retaliation
Sex Discrimination
Sexual Harassment
Sexual Orientation
Shared Ancestry/Ethnic Characteristics
Other
Other (please specify)
Incident Date
(mm/dd/yyyy)
Please list the name(s) of the subject(s) of your concern and relationship (ex. supervisor, coworker)
Please list the name(s) of witness(es) to the situation or treatment you described.
Please list the name(s) of anyone you have spoken to about your concern.
Upload supporting documentation (optional)
File attachments associated with your report.
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What resolution are you seeking?
Please select one of the following options
Please select one of the following options
I would like to speak with an EDI representative but have not yet decided to file a complaint.
I choose to use the informal resolution process in the Discrimination and Harassment Policy.
I am requesting a formal investigation under the Discrimination and Harassment Policy.
I understand by checking this box,
EDI must provide a copy of this complaint to the respondent under SUNY’s Discrimination Complaint Procedure.
Your Information
University Affiliation
Undergraduate Student
Graduate/Professional Student
State Employee
Research Foundation Employee
UB Foundation Employee
Medical Resident/Fellow
Campus Dining and Shops Employee
Applicant for Admission
Applicant for Employment
Vendor
Visitor
Gender
Gender
Female
Male
Nonbinary
Other
Prefer not to say
Would you describe yourself as transgender?
Would you describe yourself as transgender?
Yes
No
Prefer not to say
Race and Ethnicity (select as many as apply)
Race and Ethnicity (select as many as apply)
White
Black/African American
Hispanic or Latinx
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Preferred Contact Method
Preferred Contact Method
Phone
Email
Phone Number
If you would prefer to remain anonymous, please enter
Anonymous
into the
first
and
last
name
fields.
Self-reporter Affiliation
Undergraduate Student
Graduate Student
Faculty
Staff - State
Staff - RF
Staff - UBF
Staff - Other
Medical Resident or Fellow
Anonymous or Unknown
Applicant for Admission
Applicant for Employment
Department or Institution
No UB Affiliation
Other Fields
Your name
Your first name
Your last name
Your email address
Verification Code