4104-F-1 Discrimination-Retaliation Complaint Form

Complaint Number

First Name

Intial

Last Name

Street Address

City, Zip, & State

Email Address

Position

Supervisor's Name

Complaint

Identify type of discrimination, harassment, retaliation

Did the Compliant report the discrimination, including unlawful harassment, or retaliation to the Supervisor?

Yes

No

What additional facts show that a person discriminated, harassed, or retaliated against the Complainant?

Known Witnesses:

Free Text

Additional sheets or documents may be attached to this complaint, if necessary.

What is the best way to contact you?

Email

Phone

Free Text

Retaliation against a person who reports discrimination, including unlawful harassment,

is prohibited.

Complaint's Signature

Date

Please Print/Type Name

Series 4000: District Employment