Workplace Discrimination Complaint Log PDF

Record discrimination incidents, who was involved, and how the employer responded so you can attach a clean PDF to EEOC or state agency complaints.

Employee & employer

Document workplace discrimination patterns, witnesses, and reports.

Employee name

Employer / company

Department / work location

Job title

Protected characteristic involved

Brief summary of pattern

Period covered (From)

Period covered (To)

Capture each incident with what happened, witnesses, and responses.

Date

Time (optional)

Location

People involved

Witnesses

What happened

Reported to

Follow-up / response

Agency / legal notes

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Review details before sending; nothing here is legal advice or a substitute for local forms.