J:Forms\Forms (Adopted)\ Discrimination Complaint Form (Revised 9/2018)
Los Rios Community College District
Discrimination Complaint Form
Name: ________________________________________________________________________________________
Last First
Address: ______________________________________________________________________________________
Street or P.O. Box City State Zip
Phone: Day ( ) Evening ( )
E-mail Address: _________________________________________________________________________________
I Am A: Student Employee Other: ________________________________________
I Wish To Complain Against: ______________________________________________________________________
District: Los Rios Community College District College/Location: _______________________________________
Date of Most Recent Incident of Alleged Discrimination: ______________________________________________
(Non-employment complaints must be filed within one year of the date of the alleged discrimination.
Employment complaints must be filed within six months of the date of the alleged discrimination.)
I Allege Discrimination Based on the Following Category Protected under Title 5: (you must select at least one):
Age
Ancestry
Color
Ethnic Group Identification
Gender
Gender Expression
Gender Identity
Marital Status
Medical Condition
Military and Veteran Status
National Origin
Physical or Mental Dis
ability
Political Affiliation or Belief
Pregnancy or Childbirth-related condition
Race
Religion or Religious Creed
Retaliation**
Sex (includes harassment)
Sexual Identity
Sexual Orientation
Association with a person or group with one or more of these actual or perceived characteristics
_ (please provide explanation): __________________________________________________________________
Other (please provide explanation): ______________________________________________________________
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
religion, age, race, sex or whatever basis you indicated above. ** If applicable, why you believe you were retaliated
against for filing of complaint or asserting your rights to be free from discrimination on any of the above grounds.
(Attach additional pages as necessary.)
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
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What would you like the College/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 Orig
inal to College Equity Officer or to: Chancellor’s Office, California Community C
olleges
1102 Q Street, Sacramento, CA 95811-6549
Attention: Legal Affairs Division
