DISCRIMINATION COMPLAINT FORM

Name of relevant program or department*

Date of Incident(s)*

Location of Incident(s)*

Detailed description of incident or complaint*

Description of complainant’s response to incident*

Description of harm caused by the indent(s)*

Names of any witnesses to the incident(s)

Description of any physical evidence that supports the complaint

Description of what would be considered a satisfactory outcome*

Signature of the complainant*

Type in name as signature

Email address*

This field should be left blank

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