Discrimination/harassment Complaint Form (Page 2 of 2) in pdf

V. Details of Complaint

Please answer the following questions to the best of your ability. Attach

additional sheets of paper if you need more space.

Please describe the type of harassment or discrimination that you experienced,

including the events or actions, in as much detail as possible:

______________________________________________________________________________

List the people involved in harassing or discriminating against you:

______________________________________________________________________________

List any witnesses of the incident:

______________________________________________________________________________

Describe the location where the harassment/discrimination occurred:

______________________________________________________________________________

Please list all the date(s) and times when the harassment/discrimination

occurred or when the alleged harassment/discrimination first came to your

attention:

______________________________________________________________________________

What steps, if any, have you taken to resolve this issue before filing a complaint?

______________________________________________________________________________

__________________________________

_______________________

Signature of person filing complaint

Date

Received by:

Date Filed:

Title:

Please provide a duplicate copy to the complainant.

This is a model complaint form developed by Transgender Law Center and GSA Network for use in

2 of 2

California schools, but is not an official form from the CDE or any California school district.

Discrimination/harassment Complaint Form Page 2