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):
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
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Who or what entity do you believe discriminated against, harassed, or bullied  you (or someone else)?
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
 

Date and place of alleged incident(s):
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Names of any witnesses (if any):
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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.
_______________________________________________________________
_______________________________________________________________
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I agree that all of the information on this form is accurate and true to the best of my knowledge.

 

Signature:  _____________________________________________     Date:  ______________________