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):

 

q Race

q Religion

q Color                          

q Sexual Orientation

q National Origin                     

q Age

q Sex                              

q Actual or potential parental, family or marital status

q Disability                

q Pregnancy or related conditions

q 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:  _________