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: _______________
