Pregnant and Parenting Rights Complaint Form

Background Information

Reporting Party Full Name:

Employee or Student:

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Title/Position/Student Classification

Your phone number:

Your email address:

Email address must be of a valid format.

Your address:

Nature of the Complaint(Required):

This field is required.

Date of incident(Required):

This field is required.

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Please provide the date or the approximate date of the incident

Location of incident(Required):

This field is required.

Specific location (if known):

Involved Parties

Parent/Student Name

Select Gender

Select Role

Banner ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Address

Questions

Please provide the information below.

Please describe in as much detail as possible the issue that you are experiencing.(Required) This field is required.

What remedy are you seeking in relation to your complaint? Please provide as much detail as possible.(Required) This field is required.

How has this issue effected your ability to complete academic work/job duties or fully participate in activities/responsibilities as a student or employee of the University of North Carolina Pembroke?(Required) This field is required.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Background Information

Involved Parties

Questions

Supporting Documentation

Submission