Fillable Form VI.D.12.1.: Student Civil Rights Complaint: (Lone Star College System)

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Form VI.D.12.1.: Student Civil Rights Complaint: (Lone Star College System)

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Section VI.D.12. Student Civil Rights Complaints Procedures Page 4 of 6
Form VI.D.12.1.: Student Civil Rights Complaint
This form must be sent to the applicable college’s Chief Student Services Officer
Students who believe they have been discriminated because of their race, color, sex,
age, sexual orientation, religion, ethnic or national origin, disability, veteran status, or
any other protected status may file a complaint by completing and submitting this
form. Students should provide the completed form to their college’s Chief Student
Services Officer (CSSO) as soon as possible.
Student (Complainant): __________________________________________ Date: _____________________________________
Print Name
Student ID: ______________________________________________ Student Email: _____________________________________
College campus: ________________________________________
Respondent Information
Name (Respondent): ________________________________________________________________________________
Respondent Status: LSC Student LSC Employee
------------------------------------------------------------------------------------------------------------------------------
Student Civil Rights Complaint
Please describe the circumstances of your student civil rights complaint. Please attach any
additional pages, relevant documentation, or support.
Section VI.D.12. Student Civil Rights Complaints Procedures Page 5 of 6
Form VI.D.12.2.: Reported Student Civil Rights
Investigation Results
This form memorializes the reported student civil rights complaint investigation
results. The CSSO or designee decides whether the reported civil rights violation more
likely than not occurred based on the investigation. This form will be provided to the
college president.
Student (Complainant): ______________________________________ Student ID: __________________________________
Student Email: _____________________________________ Date Complaint Filed: __________________________________
Decision
I find that a student civil rights violation ______ did or ______ did not occur. This decision represents
my best judgment following a sufficient investigation into the reported student civil rights complaint.
____________________________________ ______________________________________ __________________
Printed Name Signature Date
Investigation Narrative
Summarize the investigation into the reported student civil rights complaint. Attach additional sheets
as necessary. Attach copies of Form VI.D.12.1. and other related written reports.
Respondent Information
Name (Respondent): ________________________________________________ Email: _________________________________
Respondent Status: LSC Student LSC Employee LSC college: _________________________________
Sanction(s) Recommended (if any):
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Section VI.D.12. Student Civil Rights Complaints Procedures Page 6 of 6
Form VI.D.12.3.: Reported Student Civil Rights Decision
This form memorializes the reported student civil rights complaint decision.
Student (Complainant): ______________________________________
Respondent: __________________________________________________
CSSO or designee: ____________________________________________
Investigative Result Completed: ____________________________
Date
Investigation Narrative
Summarize the complaint and investigation into the reported student civil rights complaint.
Decision
I find that a student civil rights violation ______ did or ______ did not occur. This decision represents
my best judgment following the investigation and recommendation provided by the CSSO or
designee.
Sanction(s) Recommended (if any):
__________________________________________________ _________________________________________________________
President’s Printed Name President’s Signature
_____________________________
Date
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Form VI.D.12.1.: Student Civil Rights Complaint: (Lone Star College System)

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Completed 6 October 2020

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