Code No. 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: __________________________
Approved: February 21, 2012
Reviewed: August 15, 2016
Revised: August 15, 2016