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, 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:  __________________________