Equity and Access Office Report a Concern Form "*" indicates required fields Thank you for taking the time to submit a report to the Equity and Access Office (EAO). This form may be used to report both detailed or anonymous information related to alleged violations of the Nondiscrimination and Anti-Harassment Policy or other policies EAO oversees. If you are experiencing an emergency, or if there is an imminent risk to your well-being or that of another person, contact the Northern Arizona University Police Department emergency line by dialing: 911. The EAO works to maintain privacy of information shared but cannot guarantee confidentiality. If you are not a mandatory reporter and wish to discuss the situation confidentially prior to submitting a form, please contact: University Ombuds Office (928)-523-8767 (employees and graduate assistants) Counseling Services (928)-523-2131 (all students) Employee Assistance and Wellness (928)-523-1552 (all employees)I. Personal InformationNameNAU employees: if you received a disclosure about or from someone else, you must input your name. First Last Asserted Pronouns Anonymous I wish to remain anonymous Please note that while this form allows for an anonymous report to be submitted, employees cannot make an anonymous report if a student or employee you supervise discloses that they have experienced harassment or discrimination based on protected status, including race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity and expression, or genetic information. If you have any questions regarding your obligation to report, please contact the Equity and Access Office (EAO) at (928)-523-3312. Additionally, please be aware that submitting this report anonymously can significantly limit the University’s ability to address the incident. In most cases, the University will be unable to resolve the incident without you providing specific information. If you disclose your name and contact information on this form, you may still discuss with EAO whether it is possible to remain anonymous when exploring options to address your concern. The request will be considered in light of the due process rights of all involved, the severity of the harassment, the potential risk to other members of the University community, and any related legal obligations. If the request cannot be honored, you will be advised accordingly. If you wish to discuss the situation anonymously with an EAO staff member, please call (928)-523-3312. Home PhoneCell or Message PhoneWork PhoneEmail II. Relationship to NAUAffiliation with NAU Faculty or Academic Professional Classified Staff Service Professional Administrator Student Worker Teaching Asst/Grad Asst Former employee Job Applicant Student Prospective Student Former Student NAU Affiliate Other: If other, please indicate the relationship to NAU III. Employee/Student InformationNAU ID Number Date of Hire/ Year in School Job Title/ Major College/ Department IV. Details of the IssueInvolved Individuals Add RemovePlease list everyone involved to your knowledge.Location Issue Occurred Date Issue Started or Occurred MM slash DD slash YYYY Nature of the IssueCheck all that apply: Age Color Conflict of Interest – Consensual Amorous Relationship Disability Gender Identity and/or gender expression Genetic Information National Origin Race Religion Retaliation Sex Sexual Harassment Sexual Orientation Veteran Status Other Age SubcategorySelect an OptionUnder 40Over 40Disability SubcategorySelect an OptionReasonable AccommodationAccessibilityDiscriminationRace/Color subcategorySelect an optionNative American/Alaskan NativeBlack/African AmericanHispanic/LatinoAsian/Pacific IslanderWhite/OtherIf 'Other' Please Describe: Description of Issue * RequiredIn your own words, please describe the issue, providing as much detail as you are able to share.V. Desired NAU ResponseDesired Outcome * RequiredThough the university cannot guarantee a particular outcome, we invite you to share your desired resolution for the situation. Please describe what you would consider an appropriate outcome to this report (e.g., training for area, conversation with individual(s), FYI, etc.).VI. Actions you have taken to date:Actions TakenPlease describe other individuals/resource offices you have notified.Optional: Attach Supporting Documentation Drop files here or Select files Max. file size: 20 MB. By checking the box below, I understand that this report will be forwarded to the Equity and Access Office and that the information contained herein is accurate and complete to the best of my knowledge. I understand that the Equity and Access Office cannot promise confidentiality. I will discuss any particular concerns I have regarding confidentiality with the assigned case manager.Affirmation * Required I affirm CommentsThis field is for validation purposes and should be left unchanged.