Discrimination/Bullying/Harassment Complaint Form

Date(Required)

Name(Required)

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Are you filling out this form for yourself or someone else?(Required)

For myself.

For 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)?(Required)

Date and place of incident:(Required)

At what address/building was the incident?(Required)

Names of any witnesses (if any):(Required)

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

Please describe "other":

Please describe what happened and why you believe that you or someone else has been discriminated against, harassed, or bullied. Please be as specific as possible.(Required)

Do you have any supporting documents/images you would like to share? If so, upload them here.

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 63 MB.

May we contact you?(Required)

Yes

Provide an email address and/or phone number for follow-up.

I agree that all of the information on this form is accurate and true to the best of my knowledge. Please type your name as your electronic signature. If filing anonymously, please type "anonymous."(Required)

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Ames CSD Discrimination/Bullying/Harassment Complaint Form

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