102.E4 - Discrimination Complaint Form

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, you (or someone else)?

 

 

                                                                                                

Date and place of alleged incident(s):

                                                                                                

 

Names of any witnesses (if any):

 

Nature of discrimination alleged (check all that apply):

 

           

 

 

Age

 

Sex

 

Disability

 

Sexual Orientation

 

Race/Color

 

Socio-economic Background

 

Marital Status

 

 

 

National Origin/Ethnic Background/Ancestry

 

 

 

In the space below, please describe what happened and why you believe that you or someone else has been discriminated against. 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: