Discrimination/Harassment Form

DISCRIMINATION/HARASSMENT COMPLAINT FORM


This form is to be used to file a complaint of discrimination based on race, color, religion, national origin, age, sex (including pregnancy), disability, sexual orientation, marital status, military status, domestic violence victim status, predisposing genetic characteristics, veteran status or any other protected class as defined by New York State or federal laws.

Please answer the questions below to descript the alleged Discrimination.
Discrimination Class*
Names, Job Titles, etc.
Give dates, times. Any witnesses?
Do you have documentation you could provide when we get back to you?*
Cards, letters, journals, or calendars relevant to your complaint
Have you filed this complaint with a federal, state, or local government agency?*
Have you instituted a suit or court action on this complaint?*