102.E4 - Discrimination Complaint Form

Code No. 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, 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):

	Race		Regilion
	Color		Sexual Orientation
	National Origin		Age
	Sex		Actual or potential parental, family or marital status
	Disability		Pregnancy or related conditions
	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: ___________________________

Adopted: 11/19/2007

Revised: 05/12/2026

Reviewed: 05/12/2026

dawn.gibson.cm… Thu, 07/22/2021 - 13:15

File Attachments

102.E4-DISCRIMINATION COMPLAINT FORM.docx.pdf