Fillable Executive Order 1096 Revised March 29, 2019 Attachment (California State University, Los Angeles)

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Executive Order 1096 Revised March 29, 2019 Attachment (California State University, Los Angeles)

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First Name
Executive Order 1096
Revised March 29, 2019
Attachment A
COMPLAINT
FORM
Instructions: This complaint form is for use by individuals who are eligible to file a complaint of Discrimination, Harassment, Retaliation,
Sexual Misconduct, Dating or Domestic Violence or Stalking under Executive Order 1097. 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 MI
Mailing Address
City
Cell Phone
Home Phone
Best time to call: AM/PM
State Zip Code
E-mail
What is your relationship with the California State University campus listed above?
Current Employee?
Was Early Resolution sought?
Indicate the type(s) of complaint being filed:
Retaliation
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
Yes No Former 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:
Yes No
If yes, with whom:
Date
Discrimination Harassment
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):
Medical Condition
Genetic Information
Age
Race/Color
National Origin/Ancestry
Marital Status
Religion
Gender / Sex
Gender Identity/Expression
Sexual Orientation
Disability
Military/Veteran Status
COMPLAINT FORM
1. Identify the Respondent(s) against whom your complaint is made. For each Respondent, provide the identifying information requested
below.
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.
3. Describe the specific harm you have suffered resulting from the incident(s).
4. What did you or others do to try to resolve the issue? What was the outcome?
5. Identify individuals who may have observed or witnessed the incident(s) that you described.
Last Name First Name MI
Telephone
Position/
Cell Phone
Job Title
E-mail
Last Name First Name MI
Telephone
Position/
Cell Phone
Job Title
E-mail
Page 2 of 3
Executive Order 1096 Revised
March 29, 2019
Attachment A
COMPLAINT
FORM
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.
You 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, please provide the name and telephone number.
Last Name
Print
n
ame
of
Complainant
Signature of Complainant
Date
For University Use Only: Date Complaint Received Signature
Page 3 of 3
Executive Order 1096 Revised
March 29, 2019
Attachment A
First Name MI
Telephone
Cell Phone
CERTIFICATION
I certify that the information given in this complaint is true and correct to the best of my knowledge or belief.
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Executive Order 1096 Revised March 29, 2019 Attachment (California State University, Los Angeles)

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Completed 22 July 2020

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