Date of complaint: ________________________________________________________________
Name of Complainant: ________________________________________________________________
Are you filling out this form for yourself
or someone else (please identify the
individual if you are submitting on behalf
of someone else) ________________________________________________________________
________________________________________________________________
Who or what entity is this complaint
against? ________________________________________________________________
Date and place of alleged incident(s): ________________________________________________________________
________________________________________________________________
________________________________________________________________
Name of any witnesses (if any): ________________________________________________________________
In the space below, please describe what happened. Please be as specific as possible and attach additional pages if necessary.
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
I agree that all of the information on this form is accurate and true to the best of my knowledge.
Signature: ________________________________________ Date: ____________________________________
