Discriminatory Harassment Complaint Statement. 32. Describe below in detail the alleged discriminatory harassment.Please sign your name in the signature block on this form. LAST NAME, FIRST NAME, MIDDLE INITIAL ( ) Mr. ( ) Ms. LAST FOUR DIGITS OF SOCIAL. The name, address, email, and telephone number of the employer (or employment agency or union) you want to file your charge against. Your complaint must be filed within 180 days of the discriminatory action. How do I fill this out? Please provide the required information as labeled with an asterisk so that we may contact you to discuss your request. The specialist will contact you for any additional information needed to complete this review. Harassment and Discrimination Reporting Form.