102.E4 Complaint Form (Discrimination, Anti-Bullying, and Anti-Harassment)

Code No. 102.E4

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 Religion/Creed

Background/Ancestry

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: __________________________

Approved: June 20, 2016

Reviewed:

Revised: