104.E2 - Anti-Bullying/Harassment Complaint Form

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):

_____________________________________________________

_____________________________________________________

_____________________________________________________

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, 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:  __________________________