Date of complaint:__________________________________________________________________________
Name of complainant: ______________________________________________________________________
Are you filling out this form for yourself of someone else (please identify the individual you are submitting on behalf of someone else): ______________________________________________
Who or what entity do you believe discriminated against, harassed, or bullied you (or someone else)?
______________________________________________________________________________
Name of alleged harasser or bully:_____________________________________________________________
Date and place of incident or incidents:_________________________________________________________
________________________________________________________________________________________
Name of witnesses (if any):___________________________________________________________________
_________________________________________________________________________________________
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Nature of alleged discrimination, harassment, or bullying (check all that apply):
_____Age _____Physical Attribute _____Sex _____Disability _____Sexual Orientation _____Physical/Mental Ability _____Gender Identity _____Familial Status _____Socio-economic Background _____ Political Belief _____Marital Status _____Political Party Preference _____Race/Color _____Religion/Creed _____National Origin/Ethnic Background/Ancestry _____Other – Please Specify: ___________________________________________
Please describe what happened and why you believe you or someone else has been discriminated against, harassed or bullied. Please be as specific as possible, attaching additional pages if necessary:______________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Evidence of harassment or bullying, i.e., letters, photos, etc. (attach evidence if possible):
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
I agree that all of the information on this form is accurate and true to the best of my knowledge.
Signature:______________________________________________________ Date: _____ /_____ /_____