4000.1 Form 2

4200.1

COMPLAINT FORM REGARDING SEX DISCRIMINATION (OTHER THAN SEXUAL HARASSMENT UNDER TITLE IX) (PERSONNEL)

This complaint form should be used for complaints of sex discrimination as defined on page 1 of the Board’s Administrative Regulations regarding the Prohibition of Sex Discrimination and Sexual Harassment (Personnel)

Name of the complainant           ________________________________________________

Date of the complaint     ______________________________________________________

Date of the alleged sex discrimination                 ____________________________________

Name or names of the sex discriminator(s)  ____________________________________

________________________________________________________________________

Location where such sex discrimination occurred          ______________________________

________________________________________________________________________

Name(s) of any witness(es) to the sex discrimination _____________________________

________________________________________________________________________

Detailed statement of the circumstances constituting the alleged sex discrimination     

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Remedy requested_________________________________________________________

Signature: ______________________________