DISCRIMINATION / HARASSMENT COMPLAINT FORM
University of California and UCSF policies prohibit discrimination/harassment/retaliation on the basis of race, color, national origin, religion, sex,
gender identity, pregnancy, physical or mental disability, medical condition, genetic information, ancestry, marital status, age, sexual
orientation, citizenship or status as a covered veteran.
1
Staff, faculty, student employees, and applicants for employment who believe they may have been discriminated/harassed/retaliated against are
encouraged to bring their concerns to the EEO/AA Officer to investigate and attempt to resolve the complaint.
1
For Full Text, Please see: University of California Policy on Discrimination, Harassment, and Affirmative Action in the Workplace
Name:_________________________________________________________________ Date:________________________________
Address:____________________________________________________________________________________________________
Phone:_______________________________ Email
Affiliation: Staff Faculty Student Postdoc Other
DETAILS OF COMPLAINT
Discrimination/harassment based on: (Please check all appropriate items)
Pregnancy
Disability
Ancestry
Religion
Marital Status
Retaliation
Sexual Harassment
Date(s) most recent or continuing discrimination/harassment/retaliation took place (month, day & year): ______________________
Person(s) responsible for the alleged action(s):
Name: _______________________________________________ Department: _______________________________________
What would you consider to be a successful or acceptable outcome and/or resolution to your complaint?
I certify that this information is correct to the best of my knowledge.
___________________________________________________________________________________________________________
Signature of Complainant Date
Attn: Nyoki Sacramento
UCSF Office of Title IX/EEO/AA
Box #1249
University of California, San Francisco
490 Illinois Street, Floor 11
San Francisco, CA 94143
Title9@ucsf.edu
or
EEO@ucsf.edu
Seal complaint in an envelope
marked "CONFIDENTIAL, Attn:
Nyoki Sacramento" and
deliver envelope to
490 Illinois Street, Floor 11
Age
Sex
Race
Color
Citizenship
Veteran Status
Gender
Gender Expression
Gender Identity
Medical Condition
National Origin
Sexual Orientation
Genetic Information
Other:
Clearly state your complaint, describing each incident of alleged discrimination/harassment separately.
OR DROP OFF COMPLETED FORM:
OR EMAIL TO:
CONTACT INFORMATION
Nyoki Sacramento, Dir.
EEO/AA, ADA & Title IX
UCSF, Box 1249
Phone: (415) 502-3400
Fax: (415) 476-6299
OPHD@ucsf.edu
MAIL COMPLETED FORM TO:
Location: ________________________ Relationship to you (supervisor, co-worker, other): _____________________________
___________________________________________
For each incident, please provide: 1) name of individual(s) who discriminated/harassed, 2) what happened, 3) where it happened,
4) witness names (if any) and 5) why you believe the discrimination/harassment happened. (Attach additional pages as needed)
