102.E4 - Discrimination Complaint Form

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: _____
Reviewed: _____
Revised: _____