Atlas Assistance Dogs Complaint Form
Complainant's Information
First Name
MI
Last Name
Email
Phone
Relationship to Atlas
Supervisor
My complaint includes harassment and/or discrimination
No
Yes
Harassment or Discrimination
I believe I was harassed/discriminated against because of my: (you may check more than one box)
Age
National Origin
Sexual Orientation
Disability
Medical Condition
Pregnancy
Veteran Status
Gender/Gender Identity
Race
Religion
Other
Please explain.
Person (or persons) you believed harassed you or discriminated against you
Their position:
All Complaints
For all complaints, please explain the problem, incident or conduct that is the basis of this complaint and include where and when it took place. Attach additional pages, as necessary.
Please describe any actions you have taken to attempt to resolve the issue.
Please describe any corrective action you are seeking. What outcome are you hoping for?
Suggested witnesses and contact information if known (e-mail and telephone numbers if you have them. Please bear in mind, we might contact them).
Have you discussed this complaint with anyone else?
Yes
No
Please list their contact information
Do you know of any documents that may be relevant to this matter?
Yes
No
Please attach any relevant or additional documents.
Signature
The information in this document is complete and correct to the best of my knowledge.
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Contact Information