AR 112 Discrimination Complaint Form
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
By whom Date