Fillable Eo 1097 Attachment A-complaint Form (California State University, Chico)

Fill Online, Printable, Fillable, Blank Eo 1097 Attachment A-complaint Form (California State University, Chico) Form

Use Fill to complete blank online CALIFORNIA STATE UNIVERSITY, CHICO pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Eo 1097 Attachment A-complaint Form (California State University, Chico)

On average this form takes 18 minutes to complete

The Eo 1097 Attachment A-complaint Form (California State University, Chico) form is 3 pages long and contains:

  • 1 signature
  • 27 check-boxes
  • 57 other fields

Country of origin: US
File type: PDF

U.S.A. forms for California State University, Chico

BROWSE CALIFORNIA STATE UNIVERSITY, CHICO FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Executive Order 1097
Revised March 29, 2019
Attachment A
STUDENT COMPLAINT
FORM
Executive Order 1097 provides students a systemwide procedure to file complaints alleging violations of the California State University
(CSU) systemwide policy prohibiting Discrimination, Harassment, Retaliation, Sexual Misconduct, Dating or Domestic Violence or
Stalking 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
Work Phone
Last Name First Name MI
Mailing
Address
City
Cell Phone
Home Phone
Best time to call: AM/PM
State Zip Code
E-mail
Currently a CSU Student? Yes
No
Last CSU Registration Date
Currently a CSU Applicant? Yes
No
Last CSU Application Date
Was Early Resolution sought?
Yes
No
If yes, with whom: Date
Indicate the type(s) of complaint being filed:
Discrimination
Harassment Retaliation
Sexual Misconduct Dating Violence Domestic Violence Stalking
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
STUDENT COMPLAINT FORM
1. Identify the Respondent(s) against whom your complaint is made. For each Respondent, provide the identifying information
requested below. Attach additional pages to this form if necessary.
Respondent(s) name:
Relationship/Association with the campus:
Relationship/Association to you:
2. Describe the incident(s) or event(s), date(s), time(s), and location(s) giving rise to your complaint.
Attach additional pages to this form, if necessary.
3. Describe the specific harm you have suffered resulting from the incident(s). Attach additional pages to this form, if necessary.
4. What did you or others do to try to resolve the complaint? What was the outcome?
Page 2 of 3
Executive Order 1097
Revised March 29, 2019
Attachment A
STUDENT COMPLAINT FORM
5.
Identify
individuals
who
may
have
observed
or
witnessed
the
incident(s)
that
you
described.
Last Name First Name MI
Telephone
Position/
Job Title
E-mail
Last
Name First Name MI
Position/
Job Title
E-mail
Cell Phone
Telephone
Cell Phone
6. Do you have any documents or electronic communications (including text messages or email) that support your complaint?
Yes
No
(Please list and attach a copy.)
7. Do you have any physical evidence (such as photographs, videos, blood tests or rape kits) that support your complaint? (Please describe)
8. Describe the outcome(s) you expect from filing your complaint. Be as specific as possible.
Y
ou may elect to have an Advisor present at meeting(s) and/or interview(s) which may be a Sexual Assault Victim’s Advocate. 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 will be accompanied by an Advisor, provide the name and telephone number.
Last Name
First Name
MI
Telephone
CERTIFICATION
Cell Phone
I certify that the information given in this complaint is true and correct to the best of my knowledge or belief.
Print Name of Student
Signature of Student
Date
For
University
Use
Only:
Date
Complaint
Received
Signature
Page 3 of 3
Executive Order 1097
Revised March 29, 2019
Attachment A
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Eo 1097 Attachment A-complaint Form (California State University, Chico)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 18 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document