Fillable Form Ready Complnt Form For Filing A Prtctd Disclsr 2005

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Form Ready Complnt Form For Filing A Prtctd Disclsr 2005

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HR 2005-31
CSU Channel Islands Form for Filing a Protected Disclosure
of Improper Governmental Activities and/or Significant Threats to
Health or Safety
This complaint form may be used to make a disclosure under Executive Order 929. The complaint must be
filed either with the Vice Chancellor of Human Resources, Office of the Chancellor, 401 Golden Shore,
Long Beach, CA 90802-4210, or with the campus administrator appointed by the campus president to
receive disclosures under Executive Order 929. The campus administrator appointed to receive disclosures
at CSUCI is the Associate Vice President, Human Resources, Administration Room #1609, (805) 437-
8490.
PLEASE PROVIDE ALL REQUESTED INFORMATION. INCOMPLETE FORMS WILL NOT
BE REVIEWED.
Name:
Home Address:
Campus Adress (if applicable)
Email Address:
Phone No.: Day: Evening:
Check One:
Employee or
Applicant
○ Employee
Job Title:
○ Applicant for employment
Position applied for:
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Describe fully the alleged improper governmental activity or condition that may significantly
threaten the health or safety of employees or the public. Specify what actions were taken that
constituted an improper governmental activity or a health or safety condition, by whom the
actions were taken, and the dates of such actions. (Use additional sheets of paper if necessary).
Identify all potential witnesses to the alleged improper governmental activity or health or safety
condition.
Please attach any documentation in support of your complaint. List all supporting documentation
that is attached. If documents supporting your complaint are not in your possession, describe the
documents.
I hereby swear under penalty of perjury that the contents of this written complaint are true, or are
believed to be true.
______________________ ____________________________________
Date
Name of Complainant (Please Type or Print)
_________________________________
Signature of Complainant
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Form Ready Complnt Form For Filing A Prtctd Disclsr 2005

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Completed 17 February 2020

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