Unlawful Discrimination Complaint
Unlawful Discrimination Complaint Form
Name: __________________________________________________________
Last First
Address: ________________________________________________________
Street or P.O. Box
Phone: Day
City State Zip
Evening
I Am A: Student Employee Other: ___________________
I Wish To Complain Against: _____________________________________
District: ___________________ College: ____________________________
Date of Most Recent Incident of Alleged Discrimination:
(Nonemployment complaints must be filed within one year of the date of the alleged
unlawful discrimination. Employment complaints must be filed within six months of
the date of the alleged unlawful discrimination.)
I Allege Discrimination Based on the Following Category Protected under Title 5
(you must select at least one):
Age
Ethnic Group Identification
Physical Disability
Religion Ancestry
Mental Disability
Race Sex/Gender (includes Harassment)
Color National Origin Retaliation**
Sexual Orientation Perceived to be in protected category or
associated with those in protected category
Clearly state your complaint. Describe each incident of alleged discrimination
separately. For each incident provide the following information: 1) date(s) the
discriminatory action occurred; 2) name of individual(s) who discriminated; 3)
what happened; 4) witnesses (if any); and 5) why you believe the discrimination
was because of your religion, age, race, sex or whatever basis you indicated above.
**If applicable, explain why you believe you were retaliated against for filing a
complaint or asserting your right to be free from discrimination on any of the
above grounds. (Attach additional pages as necessary.)
Sexual Harassment
Discrimination
