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: _____
