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Prohibited Harassment & Discrimination Complaint Form, APM 3-5

Name information
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Address Group: Your Address
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City/State/Zip
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Name information
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Department Information
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Job information
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Please check appropriate box(es) below. I believe that I was discriminated/harassed against based on my:

Statement of discrimination/harassment
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Please describe with as much detail as possible the events that led you to file this complaint including dates, people involved, and how the actions are related to the above checked boxes.

Complaint resolution
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Respondent Information
Please name Respondents: People against whom you are lodging this complaint
First Respondent :
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Second Respondent :
Third Respondent :
Fourth Respondent :
Additional Respondent :
Witness Information
Please name any witnesses:
First Witness :
Second Witness :
Third Witness:
Fourth Witness:
Additional Witness :
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Upload File
Maximum total attachment size: 20 MB
Only files of type: PDF,DOC,DOCX,JPG,JPEG,BMP,PNG are allowed.
Signature Information
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Clear signature
Enter signature into form field with keyboard.
FileDate
Date:

By submitting this complaint, I hereby authorize the Department of Civil Rights to obtain, inspect and/or copy relevant personnel records, including but not limited to, medical, personnel, disability, accommodations, disciplinary, or FMLA which may be needed for the investigation of my complaint.

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