5145.44 Form 2

4000.1

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: ______________________________