102E4 Equal Educational Opportunity - Discrimination Complaint Form

Code No. 102E4

EQUAL EDUCATIONAL OPPORTUNITY - DISCRIMINATION COMPLAINT FORM

Date of complaint: ___________________________________

Name of complaintant: ____________________________________________

Are you filling out this form for yourself or someone else (please identify the individual if you are submitting on behalf of someone
else):  
_____________________________________________________________________________________________

Who or what entity do you believe discriminated against, harassed, or bullied you (or someone else)?

______________________________________________________________________________________________

Date and place of alleged incident(s): _________________________________________________________________________

Names of any witnesses (if any): _____________________________________________________________________________

Nature of discrimination, harassment, or bullying alleged (check all that apply):

Approved: 02/26/14

Reviewed:

Revised: 5/15/24