Fillable Executive Order 1097 Revised June 23, 2015 Attachment (California State University, Los Angeles)

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Executive Order 1097 Revised June 23, 2015 Attachment (California State University, Los Angeles)

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Executive Order 1097
Revised June 23, 2015
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
Los Angeles
Executive Order 1097
Revised June 23, 2015
Attachment A
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 events(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 June 23, 2015
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.
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, 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
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