|
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, harassment, or bullying alleged (check all that apply):
|
|
Age |
Martial Status |
Sex |
|
|
Disability |
Race/Color |
Sexual Orientation |
|
|
Religion/Creed |
National Origin/Ethnic Background/Ancestry |
Socio-economic Background |
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: 07/01/2025
Reviewed: 07/01/2025
