Fillable EO 1097 Complaint Form

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EO 1097 Complaint Form

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STUDENT COMPLAINT FORM FOR
DISCRIMINATION/HARASSMENT/RETALIATION COMPLAINTS
Executive Order 1097 provides students a systemwide procedure to file complaints alleging violations of the California State University
(CSU) systemwide policy prohibiting discrimination, harassment and retaliation against students by the CSU, Employees, Other
Students, or Third Parties. Please fill in all of the information requested below as completely as possible and attach additional
pages to this form, if necessary.
CSU Campus
Mailing
Address
City
E-mail
Executive Order 1097
Attachment No. 1
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):
Last CSU Registration Date
Last CSU Application Date
Approximate Time of Incident
Page 1 of 3
Sexual Orientation
ReligionRace or EthnicityNationalityGender / SexDisability
Age
Was Informal Resolution sought? :
Harassment Retaliation
NoYes Currently a CSU Student?
Zip CodeState
NoYes Currently a CSU Applicant?
Best time to call:
Last Name First Name MI
Work Phone
Cell Phone
Home Phone
AM/PMDate of Incident
AM/PM
Approximate Time of Incident
Location of Incident
AM/PM
Location of Incident
Date of Incident
Genetic Information Military/Veteran Status
Yes
Indicate the type(s) of complaint being filed:
No
Discrimination
If yes, with whom: Date
Print Form
Clear Form
Page 2 of 3
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.
2. Describe the incident(s) or events(s), date(s), time(s), and location(s) giving rise to your complaint.
Attach additional pages to this form, if necessary.
STUDENT COMPLAINT FORM FOR
DISCRIMINATION/HARASSMENT/RETALIATION COMPLAINTS
1. Identify the accused(s) against whom your allegations are made. For each accused(s) provide the identifying information requested
below. Attach additional pages to this form if necessary.
Relationship/Association to you:
Relationship/Association with the campus:
Accused(s) name:
Executive Order 1097
Attachment No. 1
4. Describe the specific harm you have suffered resulting from the incident(s). Attach additional pages to this form, if necessary.
5. What did you or others do to try to resolve the complaint? What was the outcome?
Page 3 of 3
Signature of Student
Date
9. If you will be accompanied by an advisor, provide the name, address, and telephone number of your advisor.
You may elect to have an advisor present at meetings/interview(s). If you indicate you will have an advisor, you are authorizing that
individual to accompany you to any meetings and/or interview(s) regarding this complaint. The role of the advisor is limited to observing
and consulting with you.
8. Describe how you would expect the complaint to be resolved. Be as specific as possible.
(Please list and attach a copy.)
Print Name of Student
I certify that the information given in this complaint is true and correct to the best of my knowledge or belief.
AUTHORIZATION
STUDENT COMPLAINT FORM FOR
DISCRIMINATION/HARASSMENT/RETALIATION COMPLAINTS
NoYes
7. Do you have any documents that support your allegation?
6. Identify individuals who may have observed or witnessed the incident(s) that you described.
Executive Order 1097
Attachment No. 1
MIFirst NameLast Name
First Name
Position/
Job Title
MILast Name
E-mail
Telephone
Cell Phone
Cell Phone
Telephone
E-mail
Position/
Job Title
MIFirst NameLast Name
Telephone
Cell Phone
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EO 1097 Complaint Form

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Completed 19 April 2020

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