Formal Complaint of Harassment and/or Discrimination

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Please review the marked fields below.

Contact Information
(First Middle Last)
##### (e.g. 66045)
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Allegation(s)

On what basis do you believe you have been harassed or discriminated against? Please check all that apply:

Was it a person or group who harassed and/or discriminated against you?
Harasser / Discriminator #1 Contact Information

Who do you believe harassed and/or discriminated against you?

(First Middle Last)
##### (e.g. 66045)
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Harasser / Discriminator #2 Contact Information

Who do you believe harassed and/or discriminated against you?

(First Middle Last)
##### (e.g. 66045)
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Group Contact Information
##### (e.g. 66045)
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When and where did the harassment and/or discrimination occur?
(Please provide as much detail as possible)
Who witnessed the harassment and/or discrimination?

Witness #1

(First Last)
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Witness #2

(First Last)
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Witness #3

(First Last)
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Your Complaint

Describe below what you believe the person who harassed and/or discriminated against you did or did not do: *

(Please provide as much detail as possible)

Describe why you believe the harassment and/or discrimination is based on your race/color, disability, sex, religion, national origin/ethnicity/ancestry, veteran status, marital/parental status, sexual orientation, gender identity/expression, or retaliation based on a protected activity? *

(Please provide as much detail as possible)

What harm, if any, was caused to you as a result of the harassment and/or discrimination? *

Have you filed this complaint with any other Federal, State, Local Agency or any Federal, State Court, or administrative tribunal (EEOC, OCR, Kansas Commission on Human Rights)? *

When was the complaint filed and with what agency, court, or administrative tribunal?
Verification