Fillable Form IND-EEO02 Unlawful Harassment and Discrimination Complaint Form: (Pasadena City College)

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Form IND-EEO02 Unlawful Harassment and Discrimination Complaint Form: (Pasadena City College)

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Pasadena Area Community College District/ Office of Human Resources
Form IND-EEO02 Unlawful Harassment and Discrimination Complaint Form
Office of Human Resources
Unlawful Harassment and Discrimination Complaint Form
Last name: First name:
Address: City: State: Zip:
Home Phone: Cell Phone:
I am a/an: Student Faculty Staff/
Administrator
Other
I wish to complain against: Student Faculty Staff/
Administrator
Other
Name(s):
Date of most recent incident(s) of alleged harassment or discrimination:
(Non-employment complaints must be filed within one (1) year of the date of the alleged discrimination/harassment.
The complaint may also be filed with the Office for Civil Rights of the U.S. Department of Education. Employment
complaints must be filed within one hundred eighty (180) days of the date of the alleged discrimination/ harassment.
The complaint may also be filed with the U.S. Equal Employment Opportunity Commission or the Department of Fair
Employment and Housing where such complaint is within their jurisdiction.
Complaint: I allege harassment/discrimination based on the following California protected category (ies): (You must select
at least one)
Age (40 and older) Medical Condition Race/Ethnicity
Color Military or Veteran Status Religion
Gender/Gender Identity Mental Disability Retaliation
Genetic Information National Origin Sex (including pregnancy)
Marital Status Physical Disability Sexual Orientation
Perceived association with a member of a protected group
Page 1 of 2 - 1570 East Colorado Boulevard Pasadena, California 91106-2003 (626) 585-7388 FAX (626) 585-7924
Pasadena Area Community College District/ Office of Human Resources
Form IND-EEO02 Unlawful Harassment and Discrimination Complaint Form
Statement: Clearly state your complaint. Describe each incident of alleged discrimination/harassment.
For each action, provide the following information: 1) date(s) the discriminatory/harassment action occurred; 2) name of
individual(s) who discriminated/harassed; 3) what happened; 4) witnesses (if any); and 5) why you believe the
discrimination/harassment was because of protected group status [basis you indicated above] and/or, if applicable, why
you believe you were retaliated against for filing a complaint or asserting your rights. (Attach additional pages as
necessary.)
Witnesses: List name(s) and contact number(s) of anyone who may have witnessed the incident:
Name: Contact Number:
Name: Contact Number:
Name: Contact Number:
Resolution: What would you like the District to do to resolve this issue?
Have you addressed this issue directly with the Accused? Yes No Date:
If so, describe the process and response (if any):
I certify that this information is correct to the best of my knowledge.
Signature: Date:
Send original to:
Vice President of Human Resources
Office of Human Resources
1570 E. Colorado Boulevard
Room C204
Pasadena, CA 91106
(626) 585-7388
Complaint may also be filed with:
California Community Colleges
Chancellor’s Office
1002 Q Street
Sacramento, CA 95811
(916) 445-8752
Superintendent/President
President’s Office
1570 E. Colorado Boulevard
Room C235
Pasadena, CA 91106
(626) 585-7201
Page 2 of 2 - 1570 East Colorado Boulevard Pasadena, California 91106-2003 (626) 585-7388 FAX (626) 585-7924
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Completed 5 September 2020

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