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):
_____________________________________________________
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: April 3, 2023; October 27, 2025
Reviewed: April 3, 2023; October 27, 2025
Revised: April 3, 2023; October 27, 2025