Name of complainant: _________________________________________________________________
Position of complainant: ________________________________________________________________
Name of student or employee target: _______________________________________________________
Date of complaint: ____________________________________________________________________
Name of alleged harasser or bully: ________________________________________________________
Date and place of incident or incidents: ___________________________________________________
Nature of Discrimination or Harassment Alleged (Check all that apply.)
___ Age ___ Physical Attribute ___ Sex
___ Disability ___ Political Belief ___ Sexual Orientation
___ Familial Status ___ Race/Color ___ Socio-economic Background
___ Marital Status ___ Religion/Creed ___ Other – Please Specify
___ National Origin/Ethnic Background/Ancestry
Description of misconduct: ______________________________________________________________
_________________________________________________________________
_________________________________________________________________
Name of witnesses (if any) : ____________________________________________________________
_________________________________________________________________
Evidence of harassment or bullying, i.e., letters, photos, etc. (attach evidence if possible):
_________________________________________________________________
_________________________________________________________________
Any other information: _________________________________________________________________
_________________________________________________________________
I agree that all of the information on this form is accurate and true to the best of my knowledge.
Signature: ________________________________
Date: / /
