Executive Order 1096
Revised March 29, 2019
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.
Last Name MI
Best time to call: AM/PM
State Zip Code
What is your relationship with the California State University campus listed above?
Was Early Resolution sought?
Indicate the type(s) of complaint being filed:
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:
If yes, with whom:
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):
Gender / Sex