AR 112 - Discrimination Complaint Form

Name of complainant                                                                                                                           

Where did or is the incident(s) occur (ring) (building, grounds)?                                                          

When did or is the incident(s) occur(ring)? Date                                    Time                                        

Was or is anyone else present at the time the incident(s) occurred or is occurring?                              

Who was or is involved in the incident(s)?                                                                                           

What happened or is happening (nature of complaint)?                                                                        

How does compliant want the incident(s) or complaint resolved?                                                          

Name of person providing information for the form                                                                              

Name of person completing form                                                                      Date                            

Signature of complainant                                                                                  Date                            

Action taken:

By whom                                                                                   Date                                        

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