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Book Policy Manual
Section 4000 - Personnel Certified/Non-Certified
Title Discrimination Complaint Form
Code 4118.011-F
Status Active
Adopted October 1, 2017
DISCRIMINATION COMPLAINT FORM
(For complaints based on race, color, religion, age, sex, marital status, sexual orientation, national origin, ancestry,
disability (including pregnancy), genetic information, veteran status or gender identity or expression)
Name of the complainant ___________________________________________________
Date of the complaint ______________________________________________________
Date of the alleged discrimination/harassment __________________________________
Name or names of the discriminator(s) or harasser(s) ________________________
_______________________________________________________________________________________
Location where such discrimination/harassment occurred ________________________
_____________________________________________________________________________________
Name(s) of any witness(es) to the discrimination/harassment Detailed statement of the circumstances constituting the
alleged discrimination or harassment
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Proposed remedy:________________________________________________________________
______________________________________________________________________________