(See Discrimination Complaint Form included below.) 5. 7. Basis of alleged discrimination: Check ONLY the boxes that you believe were the reasons for discrimination and fill in specifics only for those reasons.ALLEGED BASIS OF HARASSMENT OR DISCRIMINATION (Check all that apply):. E. Responsibilities of Employees. INSTRUCTIONS: Complete and submit this form within 180 calendar days of the last act that you believe was discriminatory or harassing. This type of harassment is a form of employment discrimination. E. Responsibilities of Employees. When an employee is a victim of workplace discrimination, having evidence and documentation to back up a claim is important. In the "Anti-Discrimination" section of this policy. Nondiscrimination and Anti-Harassment.