104.2CF/104.1E2 - 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): _______________________________________________________________________________
______________________________________________________________________________
Describe requested remedy or solution (if any): _______________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________
Names of any witnesses (if any): ___________________________________________________
Nature of discrimination, harassment, or bullying alleged (check all that apply):
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Age |
Physical Attribute |
Sex |
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Disability |
Physical/Mental Ability |
Sexual Orientation |
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Familial Status |
Political Belief |
Socio-economic Background |
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Gender Identity |
Political Party Preference |
Other - Please Specify: |
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Marital Status |
Race/Color |
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National Origin/Ethnic Background/Ancestry |
Religion/Creed |
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In the space below, please describe what happened and why you believe 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: _________________________
*Adopted: 12/13/10
*Reviewed: 05/14/12
*Revised: 02/8/16
*Revised: 04/04/16
*Reviewed: 02/08/21
