Fillable EO 1096 Complaint Form Discrimination Complaint Form

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EO 1096 Complaint Form Discrimination Complaint Form

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Executive Order 1096
Attachment No. 1
COMPLAINT FORM FOR
DISCRIMINATION/HARASSMENT/RETALIATION COMPLAINTS
Instructions: This complaint form is for use by individuals who are eligible to file a complaint of Discrimination, Harassment or Retaliation
under Executive Order 1096. Please fill in all of the information requested below as completely as possible and attach additional pages
to this form, if necessary.
CSU Campus Department
Last Name First Name MI
Mailing Address
City State Zip Code
E-mail Home Phone Work Phone
Mobile Phone Best time to call: AM/PM
What is your relationship with the California State University campus listed above?
Current Employee?
Yes No Former a Employee? Yes No
Last Date of Employment
An applicant for employment?
Yes No A Third Party? Yes No
Please specify your relationship with the University:
Was Informal Resolution sought?
Yes No
If yes, with whom:
Date
Indicate the type(s) of complaint being filed:
Discrimination Harassment
Retaliation
If you are filing a Discrimination or Harassment complaint, indicate the Protected Status(es) that was/were the basis(es) of the alleged
Discrimination or Harassment (Please select all that apply):
Race/Color
National Origin/Ancestry
Marital Status
Religion
Gender / Sex
Gender Identity/Expression
Sexual Orientation
Disability
Military/Veteran Status
Medical Condition
Genetic Information
Age
If you are filing a Retaliation complaint, indicate the activity(ies) you engaged in that was/were the basis(es) for the alleged Retaliation.
Page 1 of 3
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COMPLAINT FORM FOR
DISCRIMINATION/HARASSMENT/RETALIATION COMPLAINTS
Executive Order 1096
Attachment No. 1
1. Identify the Accused against whom your complaint is made. For each Accused, provide the identifying information requested below.
Accused's name:
Relationship/Association with the campus:
Relationship/Association to you:
2. Describe the incident(s) or events(s), date(s), time(s), and location(s) giving rise to your complaint.
3. If you are filing a Sexual Harassment or Sexual Violence complaint, including Domestic Violence, Dating Violence, or Stalking,
please describe the conduct, including date(s), time(s), and location(s). Attach additional pages to this form, if necessary.
4. Describe the specific harm you have suffered resulting from the incident(s).
5. What did you or others do to try to resolve the issue? What was the outcome?
Page 2 of 3
COMPLAINT FORM FOR
DISCRIMINATION/HARASSMENT/RETALIATION COMPLAINTS
Executive Order 1096
Attachment No. 1
6. Identify individuals who may have observed or witnessed the incident(s) that you described.
Last Name First Name MI
Telephone
Position/
Job Title
Mobile Phone
E-mail
Last Name First Name MI
Telephone
Position/
Job Title
Mobile Phone
E-mail
7. Do you have any documents that support your complaint?
Yes No
(Please list and attach a copy.)
8. Describe the outcome(s) you expect from filing your complaint. Be as specific as possible.
Complainants may elect to have an Advisor present at meeting(s) and/or interview(s). If you indicate you will have an Advisor, you are
authorizing that individual to accompany you to any meeting(s) and/or interview(s) regarding this complaint. The role of the Advisor is
limited to observing and consulting with you.
9. If you have selected an Advisor, please provide the name and telephone number of your Advisor.
Last Name First Name MI
Telephone
Mobile Phone
AUTHORIZATION
I certify that the information given in this complaint is true and correct to the best of my knowledge or belief.
Print Name of complainant
Signature of complainant
Date
For University Use Only: Date Complaint Received _______________ Signature__________________________________
Page 3 of 3
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EO 1096 Complaint Form Discrimination Complaint Form

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Completed 19 April 2020

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