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  ____ Sex

____Disability ____ Sexual Orientation

____Socio-economic Background

____ Marital Status ____ Race/Color

____ National Origin/Ethnic Background/Ancestry  ____ Religion/Creed

____ Other – Please Specify: _________________________________

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: __________