Name and title(s) of person(s) causing discrimination and/or harrassment:
Name(s), title(s), and contact information of witness(es) or person(s) who may have relevant information or evidence helpful to the investigation and resolution of the complaint:
Describe in detail the circumstances surrounding your allegations of discrimination and/or harassment. Please include date(s), time(s) and locations where the act(s) occcurred and use a separate sheet of paper if more room is needed and attach to this document.
What remedy are you seeking?
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