103.E4 - Discrimination Complaint Form

103.E4 - Discrimination 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 you (or someone else)?

_____________________________________________________

Date and place of alleged incident(s):

_____________________________________________________

_____________________________________________________

_____________________________________________________

Names of any witnesses (if any):

_____________________________________________________

 

Nature of discrimination alleged (check all that apply):

 

Age

 

Religion

 

Disability

 

Creed

 

Gender Identity

 

Sex

 

Marital Status

 

Sexual Orientation

 

National Origin

 

Socioeconomic Status

 

Race/Color

 

Other – Please Specify

 

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.

_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________

I agree that all of the information on this form is accurate and true to the best of my knowledge.

Signature: _____________________________________            Date:  __________________________

 

dawn.gibson.cm… Tue, 12/07/2021 - 15:05