104.E1 - Discrimination, Anti-Bullying, and Anti-Harassment Complaint Form

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