Discrimination Form

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Name*

Date*

Address*

Please answer the questions below to descript the alleged Discrimination.

Discrimination Class*

Race

National Origin

Disability

Military Status

Age

Sex

Religion

Sexual Orientation

Domestic Vitim Status

Sexual Harassment

Marital Status

Predisposing Genetic Characteristics

Stalking

What are you alleging?*

Who committed the alleged harassment/discrimination?*Names, Job Titles, etc.

What exactly occurred or was said?*

When did this occur? Is it ongoing?*Give dates, times. Any witnesses?

How did it effect you?*

Did you tell anyone about the harassment/discrimination? If so, who? Provide names, titles and telephone numbers.*

Do you have documentation you could provide when we get back to you?*

Yes

No

Cards, letters, journals, or calendars relevant to your complaint

How would you like your complaint to be resolved?*

Have you filed this complaint with a federal, state, or local government agency?*

Yes

No

Have you instituted a suit or court action on this complaint?*

Yes

No

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