Executive Order 1097
Revised June 23, 2015
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.
Last Name First Name MI
Best time to call: AM/PM
State Zip Code
Currently a CSU Student? Yes
Last CSU Registration Date
Currently a CSU Applicant? Yes
Last CSU Application Date
Was Early Resolution sought?
If yes, with whom: Date
Indicate the type(s) of complaint being filed:
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):
If you are filing a Retaliation complaint, indicate the activity(ies) you engaged in that was/were the basis(es) for the alleged Retaliation.
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