104.E1 Complaint Form (Discrimination, Anti-Bullying and Anti-Harassment)

Date of complaint: _____________________________________________________

Name of Complainant: _____________________________________________________

Are you filling out this form for yourself or someone else (please identify the individual if you are submitting on behalf of someone else): _________________________________________________________________________________________________________

Who or what entity do you believe discriminated against, harassed, or bullied you (or someone else)? _____________________________________________________

Date and place of alleged incident(s): __________________________________________________________________________________________________________ _____________________________________________________

Names of any witnesses (if any): _____________________________________________________

Nature of discrimination, harassment, or bullying alleged (check all that apply):

____ Age ____ Physical Attribute ____ Sex

____ Disability ____ Physical/Mental Ability ____ Sexual Orientation

____ Familial Status ____Political Belief ____ Socio-economic Background

____ Gender Identity ____ Political Party Preference ____ Other – Please Specify: __________________________

____ Marital Status ____ Race/Color ____ National Origin/Ethnic Background/Ancestry

____ Religion/Creed

In the space below, please describe what happened and why you believe that you or someone else has been discriminated against, harassed, or bullied. Please be as specific as possible and attach additional pages if necessary. _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I agree that all of the information on this form is accurate and true to the best of my knowledge.

Signature: ___________________________ Date: _______________