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:  __________________________