Discrimination Report Form


If you are the complainant please provide your information below. If you are reporting on behalf of someone please enter their information below.


Please provide information about the person you are filing the complaint against below.

Third party or referral

Please provide your information below if you are reporting an incident on behalf of someone else.

Nature of discrimination

Please indicate the nature of discrimination by selecting  from the drop down list below. There can be more than one form of discrimination selected.

Date and time of incident

When did the alleged incident occur?

1000 characters remaining.
Location of incident

Where did the alleged incident occur?

1000 characters remaining.

Who was involved in the incident?

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Have you reported this to anyone? If so who did you report it to, and when did you report it?

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Were there any witnesses?

1000 characters remaining.
Additional information

Please provide any information you feel may be helpful.

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By submitting this form I acknowledge that to the best of my knowledge I have completed this form truthfully.

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