1.  COMPLAINTANT

NAME:  

ADDRESS LINE 1:  

ADDRESS LINE 2:  

CITY:    STATE:    ZIP CODE: 

PHONE:   E-MAIL: 

2.  PERSON DISCRIMINATED AGAINST (IF DIFFERENT FROM COMPLAINTANT)

NAME:  

ADDRESS:  

CITY:    STATE:    ZIP CODE:  

3.  INCIDENT INFORMATION

DATE OF INCIDENT:  

TIME OF INCIDENT:  

LOCATION OF INCIDENT:  

DEPARTMENT / PROGRAM / ACTIVITY INVOLVED (IF KNOWN):

4.  BASIS OF COMPLAINT

PLEASE CHECK THE BASIS OF DISCRIMINATION THAT APPLISE:

RACE  COLOR  NATIONAL ORIGIN  SEX  DISABILITY (ADA)  AGE  LIMITED ENGLISH PROFICIENCY  OTHER:  

5.  COMPLAINT DESCRIPTION

PLEASE DESCRIBE THE ALLEGED DISCRIMINATION IN DETAIL.  INCLUDE NAMES OF INDIVIDUALS INVOLVED, WITNESSES, AND OTHER RELEVANT CIRCUMSTANCES.

6.  WITNESS INFORMATION (IF ANY)

NAME:  

ADDRESS:  

CITY:    STATE:    ZIP CODE:  

7.  HAVE YOU FILED THIS COMPLAINT WITH ANY OTHER AGENCY

    YES  NO

    IF YES, PLEASE INDICATE THE AGENCY:

    FEDERAL AGENCY  STATE AGENCY  LOCAL AGENCY  COURT

    AGENCY NAME:    DATE FILED:  

8.  SIGNATURE

    I CERTIFY THAT THE INFORMATION IN THIS COMPLAINT IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. 

    NAME:  

    DATE: