COMPLAINT FORM
(Anti-Discrimination 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 and/or harassed. 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: ___________________________
(1/8/2018)