104.E1 - Discrimination, Anti-Bullying, and Anti-Harassment 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: __________________________