File: GB-F

REPORT OF DISCRIMINATION

Name of Complainant:

For Employees, Position:

For Applicants, Position Applied For:

Address and Phone Number:

Date(s) of Alleged Discrimination:

Name of person(s) you believe discriminated against you or others:

Please describe in detail the incident(s) of alleged discrimination, including where and when the incident(s) occurred. Please name any witnesses that may have observed the incident(s). Attach additional pages if necessary.

Please describe any past incidents that may be related to this complaint.

I certify that the information provided in this report is true, correct and complete to the best of my knowledge.

________________________________________

Signature of Complainant Date

Complaint Received By: __________________________________________

Compliance Officer/Other Date

3/06 RCPS ROCKINGHAM COUNTY SCHOOL BOARD