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):
__________________________________________________________________________________
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Who or what entity do you believe discriminated against, harassed, or bullied you (or someone else)?
__________________________________________________________________________________
__________________________________________________________________________________
 

Date and place of alleged incident(s):
__________________________________________________________________________________

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Names of any witnesses (if any):
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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.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

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I agree that all of the information on this form is accurate and true to the best of my knowledge.

Signature: _____________________________________ Date: __________________________

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