Code of Conduct Complaint Form

A. Complainant's Information

The person making the complaint and/or directly affected by the behaviour.

Name(Required)

First Last

Student Number/Staff Email(Required)

Program/Department(Required)

Campus/Satellite Location(Required)

Student/Staff Email(Required)

Phone

What is the best way to contact you?

Phone

Please select the response that best describes you.(Required)

I am the person directly affected by the situation.

I am submitting the complaint on behalf of the person/people directly affected by the situation and the person/people are aware that I am submitting the complaint on their behalf.

Their Name(Required)

If submitting the complaint on someone’s behalf, please provide their details below to the best of your knowledge.

First Last

Their Student Number/Staff Email(Required)

Their Email Address(Required)

Their Program/Department(Required)

Their Address (if known)

Street Address Address Line 2 City Province Postal Code

B. Respondent's Information

The person/people who are the subject of the complaint. Please provide details to the best of your knowledge. If you do not know, please indicate NA in the fields below.

Name (if known)

First Last

Student Number (if known)

Email (if known)

Address (if known)

Street Address Address Line 2 City Province Postal Code

Program/Department (if known)

C. Incident Details

Please tell us about the incident in as much detail as possible (who, what, when, where).(Required)

If there are any witnesses, please provide their name(s) and contact information.(Required)

Did you tell anyone about this incident (peer, staff, faculty, security, police etc.)? If yes, please let us know who and provide as much detail as possible.(Required)

Is there any other information of which we should be aware?(Required)

D. Consent

I confirm that the information provided is true and correct to the best of my knowledge. I understand the information provided on this form may be used by Loyalist College to launch and conduct an investigation. This may include contacting the person making the complaint and any person identified through this form. If you have any questions about the form, please email conductcomplaints@loyalistcollege.com.(Required)

Yes

Signature (please include your full name)(Required)

Date(Required)

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Code of Conduct Complaint Form

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