Anonymous Report of Discrimination Form


Anonymous Report of Discrimination

Status of the person experiencing the discrimination:

Basis of Complaint (check all that apply):

Accused Perpetrator/Respondent status:

Gender of Accused Perpetrator / Respondent:

Race of Respondent:

Please describe in detail the incident(s) you consider to be discriminatory, harassing, or retaliatory. Please provide the first and last names of all individuals involved for each incident.
i.e., Termination, Resignation, Suspension, Demotion, Written Reprimand, Lower Class Grade, Dropped the Class, Emotional Distress, Poor Performance Evaluation, etc.)
Is anyone else aware of the incident?:

List of person(s) who were treated more favorably than you under similar circumstances
List any person(s) who may have experienced a similar incident from the respondent