===== PAGE 1 =====
Date Received on:_____

# Incident / Complaint Report Form

BY:_____



Complainant's Name: ___

Mailing Address: ___

Phone: ___

## Complainant's Status:

Employee

Department Customer

□ Job Applicant

Date, time, and place of the incident(s): ___

## Documentation:

Please attach copies of any documents or material you believe are relevant.

## Witnesses:

Did anyone witness the incident(s)? If so, please list names and phone numbers of any witnesses to the incident(s). Use additional pages, if necessary.

Name: ___

_Phone: _____

Name: ___

_Phone: _____

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## Statement:

Please describe the incident(s) as clearly and concisely as possible. Provide as much detail as you can recall, including when and where the events occurred and who said what to whom. Explain why you believe the conduct or treatment was discriminatory. Use additional pages, if necessary.

## Action Sought:

Please describe what you would like to see done to correct the situation.

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## Complaint Authorization

I understand that complete confidentiality cannot be maintained in the process of handling informal and formal complaints. I agree that this statement of allegations may be used during the investigation of the incident.

I affirm that this complaint statement is true, accurate, and complete to the best of my knowledge.