If you have experienced prejudice or discrimination of any kind then you need to report it and one way of doing this is by filling out a discrimination complaint form. This enables your complaint to be documented. Whatever form of harassment you have gone through you need to report it.
Name of the complainant: __________________________________________________
Address: ________________________________________________________________
Tel: ____________________________________________________________________
Mobile: _________________________________________________________________
Email: __________________________________________________________________
Name of person or organization accused of alleged discrimination: __________________
Address: ________________________________________________________________
Tel: ____________________________________________________________________
Mobile: _________________________________________________________________
Email: __________________________________________________________________
Describe the nature of the alleged discrimination: _______________________________
___________________________________________________________________
Date of the alleged discrimination: ___________________________________________
Give details of those involved in the alleged discrimination:
Name Position Relationship Describe involvement
_______________ _______________ ________________ __________________
_______________ _______________ ________________ __________________
_______________ _______________ ________________ __________________
_______________ _______________ ________________ __________________
_______________ _______________ ________________ __________________
What actions have you taken concerning the alleged discrimination: _______________
_____________________________________________________________________
Additional comments: ___________________________________________________
_____________________________________________________________________
Complainant’s signature: ___________________________ Date: ______
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