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Last First (Non-employment complaints must be filed within (Mt. San Jacinto Community College District)

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Appendix A
Unlawful Discrimination Complaint Form
Name: ______________________________________________________________________________________
Last First
Address: _______________________________________________________________________________
Street or P.O. Box City State Zip
Phone: Day ( ) _________________________________ Evening (_____)______________________
I Am a: Student Employee Other: _________________________
I Wish To Complain Against: ______________________________________________________________
District: ______________________________________________ College: ____________________________
Date of Most Recent Incident of Alleged Discrimination: _____________________________
(Non-employment complaints must be filed within one year of the date of the alleged unlawful discrimination.
Employment complaints must be filed within six months of the date of the alleged unlawful discrimination.)
I Allege Discrimination Based on the Following Category Protected under Title 5 (you must select at least
one):
Age Ethnic Group Identification Physical Disability Retaliation**
Ancestry Mental Disability Race Sex/Gender (includes Harassment)
Color National Origin Religion Sexual Orientation
Perceived to be in protected category or associated with those in protected category
Clearly state your complaint. Describe each incident of alleged discrimination separately. For each incident
provide the following information: 1) date(s) the discriminatory action occurred; 2) name of individual(s) who
discriminated; 3) what happened; 4) witnesses (if any); and 5) why you believe the discrimination was because of
your religion, age, race, sex or whatever basis you indicated above. **If applicable, explain why you believe you
were retaliated against for filing a complaint or asserting your right to be free from discrimination on any of the
above grounds. (Attach additional pages as necessary.)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
What would you like the District to do as a result of your complaint –what remedy are you seeking?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
I certify that this information is correct to the best of my knowledge.
___________________________________________________ _________________________________
Signature of Complainant Date
Send Original to:
Mt. San Jacinto College or Chancellor’s Office
Attention: Human Resources Attention: Legal Affairs Division
1499 N. State Street 1102 Q Street
San Jacinto, California 95283-2399 Sacramento, California 95811
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Completed 5 September 2020

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