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Date: |
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Date of initial complaint:
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Name of Complainant (include whether the Complainant is a student or employee): |
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Date and place of alleged incident(s): |
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Nature of discrimination alleged (check all that apply):
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Description of incident witnessed: _________________________________________________________
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Additional information: _________________________________________________________________
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I agree that all of the information on this form is accurate and true to the best of my knowledge.
Signature: _____________________________________ Date: __________________________