DISCRIMINATION COMPLAINT FORM
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Date of Complaint: |
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Name of Complainant: |
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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 you (or someone else)? |
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Date and place of alleged incident(s): |
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Names of any witnesses (if any): |
Nature of discrimination alleged (check all that apply):
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Race |
Religion |
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Color |
Sexual Orientation |
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National Origin |
Age |
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Sex |
Actual or potential parental, family or marital status |
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Disability |
Pregnancy or related conditions |
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Creed |
In the space below, please describe what happened and why you believe that you or someone else has
been discriminated against. 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: __________________________
Approved: April 13, 2026
Reviewed: April 13, 2026
Revised: April 13, 2026