Discrimination Complaint Reporting Form

Background Information

Your name

Employee or student

Your phone number

Your email address

Your local address

Date of incident

Location of incident

Alleged Person(s)

Name

Role

Complaint Details & Action Requested

1. The alleged discrimination is based on (please check all that apply)

2. Is the alleged discrimination continuing?

3. Have you filed an informal complaint about the discrimination previously?

4. If you answered Yes to Question 3, on what date did you file the informal complaint?

5. Please indicate how you would like your complaint addressed (see link to Grievance Procedure above)

6. Have you filed this charge with a federal, state, or local government agency?

7. If you answered Yes to Question 6, please indicate which agency and the date when you filed the charge

8. Have you initiated a suit or court action regarding this charge?

9. If you answered Yes to Question 8, please indicate which court and the date when you initiated this action

10. Describe briefly the act which occurred and your reason for concluding that it was discriminatory

Honesty Statement & Report Submission

I affirm that I have carefully reviewed the charge(s) documented above and that it is true to the best of my knowledge, information and belief.

Leave this field blank

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