Name of plaintiffname of defendantname of plaintiff tityname of plaintiffname of defendantname of defendantdescribe other covered relationship todefendantname of plaintiffspecify basis of association or relationship,g., the brother of [name of disabled person]e.g., physicalconditionname of disabled persone.g., physical conditionname of defendantspecify reason, e.g., [name of disabledperson] was covered under [plaintiff]222s employer-provided health careplanname of defendantname of plaintiffname of disabled personspecify, e.g., [name of disabledperson] has a disability with a genetic component and[name of plaintiff]may develop the disability as wellname of plaintiffname of disabled persone.g., conditionname of plaintiffname of defendantname of plaintiffSpecify other basis for associational discrimination name of plaintiff[name of defendant]other adverseemployment actionname of plaintifforname of defendantname of plaintifforname of plaintiffname of plaintiffname of disabled personname of defendantother adverse employment actionname ofplaintiffname of plaintiff name of defendant name of plaintiff New December 2014; Revised May 2017