104.E1 - Complaint Form (Discrimination, Anti-Bullying, and Anti-Harassment)

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:____________________________