Date of Complaint
Name of Complaint
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:
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 ________________________________