Fillable DISCRIMINATION and HARASSMENT COMPLAINT FORM (College of the Desert)

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DISCRIMINATION and HARASSMENT COMPLAINT FORM (College of the Desert)

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HR Revised 01/27/2020
Page 1 of 3
Office of Human Resources
(760) 773-2529
www.collegeofthedesert.edu
DISCRIMINATION and HARASSMENT COMPLAINT FORM
Instructions: Please print clearly and provide as much information requested below as possible. Return completed
and signed form to Human Resources. If assistance is needed to complete this form, please contact
Human Resources.
COMPLAINANT INFORMATION
Name:
Date:
Mailing Address:
Department/Division:
Campus Extension:
Best phone number to reach you:
Employee
Relationship to
College of the Desert
(check one)
Volunteer
Student Applicant
Community Member Other
__________________
If you are an employee, what is your title/classification?
If you are a student, what is your date of last registration?
Indicate the ground(s) on which you are making your complaint of discrimination/harassment.
Sex
Race
Gender Identity
Color
Sexual Orientation
National Origin
Marital Status
Ancestry
Age
Citizenship Status
Other:
Retaliation (Please indicate the type of retaliation by checking the applicable boxes above.)
Identify the dates that the alleged discrimination and/or retaliation took place.
Earliest Date(s): Latest Date(s):
_________________________ _________________________
_________________________ _________________________
HR Revised 01/27/2020
Page 2 of 3
1. Identify the person or persons against whom your allegations are made, their working relationship to you (supervisor,
professor, co-worker, student, etc…) and their work or classroom location:
2. Describe the nature of your complaint, the incident(s), date(s), and place(s). Attach additional pages to this complaint if
necessary.
3. To whom have you gone for resolution of the complaint? What did you or others do to try to resolve the complaint?
What was the outcome?
4. Identify others who may have observed or witnessed the incident(s) that you described:
Name:
Address:
Telephone:
Position:
5. Identify others you believe may have experienced the same situation.
Name:
Address:
Telephone:
Position:
HR Revised 01/27/2020
Page 3 of 3
6. Do you have any documents that support your allegation? (Please list and attach a copy.)
7. Describe how you would like the complaint to be resolved. Be as specific as possible.
8. If you are to be represented, provide the name, address, and telephone number of your representative.
COMPLAINTANT SIGNATURE
To the best of my knowledge, the information I have submitted is accurate. I am aware that an informal process is available
to resolve the complaint, and feel that a formal complaint is appropriate to resolve the discrimination and harassment I
allege in this complaint. I understand that I may have rights to relief under the state and federal laws, and that filing a
formal complaint does not necessarily affect the time within which I must file a complaint with the agencies or courts that
enforce those laws. I understand that if I am a member of a collective bargaining unit, I may have rights to grieve the
actions in my complaint, and that filing this complaint does not substitute for that process or give me more time to grieve
any of those actions. I agree to cooperate within reason with any investigation conducted by the college into this matter.
Print Name:
Signature:
Date:
Please return this completed form to the Human Resources Office, located at 43-500 Monterey Ave., Palm Desert,
CA 92260.
If you have any questions, please contact the Human Resources Department at 760-773-2529.
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DISCRIMINATION and HARASSMENT COMPLAINT FORM (College of the Desert)

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Completed 25 July 2020

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