Discrimination Complaint Form Page 3
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12Page 3 of 12 – U.S. Department of Education, Office for Civil Rights Discrimination
Complaint Form, Consent Form, and Complaint Processing Procedures
Discrimination based on disability (specify)
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Discrimination based on age (specify)
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Retaliation because you filed a complaint or asserted your rights (specify)
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Violation of the Boy Scouts of America Equal Access Act (specify)
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5.
Please describe each alleged discriminatory act. For each action, please include the
date(s) the discriminatory act occurred, the name(s) of each person(s) involved and,
why you believe the discrimination was because of race, disability, age, sex, etc. Also
please provide the names of any person(s) who was present and witnessed the
act(s) of discrimination.
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