Name of Complainant (the person believed to have EXPERIENCED the harassment or discrimination)

First Name

Last Name

How would you describe the Complainant?

Student

DPS Employee

Parent, guardian, or other party living in the house

Community member

Not Listed

Name of the Respondent (the person believed to have perpetrated the harassment or discrimination)

First Name

Last Name

How would you describe the Respondent?

Student

DPS Employee

Parent, Guardian, or other party living in the home

Community member

Not Listed

Date that the incident took place:

MM

DD

YYYY

Does the alleged conduct relate to the complainant belonging to any of the following protected classes or any of the following types of potential discrimination? If so, select the applicable option below:

Race

Color

Gender

Sexual orientation

Gender Identity or expression

Transgender status

Religion

National origin

Immigration/citizenship status

Ancestry

Age

Marital status

Pregnancy status

Veteran status

Disability

Genetic information of an employee

Participant in a discrimination investigation

None of the above

Have you already reported this concern to an AUL employee?

Yes

No

What is your name?

First Name

Last Name

What is your phone number?

(###)

###

####