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: __________________________
