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2. Complainant:*
3. Phone:*
5. Address: (City, State, Zip):*
6. Email:*
8. Person Discriminated Against if Different from Above:
9. Phone:
11. Email:
12. Date of Incident:*
    Date of Incident:
14. Date and place of alleged discriminatory actions. Please include earliest date of discrimination and most recent date of discrimination.*
16. Explain as briefly and clearly as possible what happened and how you were discriminated against. Indicate who was involved. Be sure to include how other persons were treated differently than you. Also, attach any written material pertaining to your compliant (attach additional pages, if necessary)*
18. Atttachments*

    1. Yes
    2. No
20. Attachments:
22. The complaint will not be accepted if it has not been signed. Please sign and date this complaint form below. You may attach any written materials or other supporting information tha you believe is relevant to the complaint.
24. Electronic Signature*
25. Date*
    Date
27. Submit completed form to:
    Bev Bartlett
    Human Resource Officer
    234 Main St. PO Box 390 Chadron, NE 69337
    personnel@chadron-nebraska.com
Leave This Blank:


29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit Submit and Print

* indicates a required field