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102.E4 COMPLAINT FORM

Code No. 102.E4

 

COMPLAINT FORM

(Discrimination, Anti-Bullying, and Anti-Harassment)

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, 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:

 

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.

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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

Signature: _____________________________________      Date:  __________________________

 

Approved:  8/8/2016                          Reviewed: __________                              Revised:  ________