Unlawful Discrimination Complaint
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Unlawful Discrimination Complaint Form
Name: __________________________________________________________
Last First
Address: ________________________________________________________
Street or P.O. Box
Phone: Day
City State Zip
Evening
I Am A: Student Employee Other: ___________________
I Wish To Complain Against: _____________________________________
District: ___________________ College: ____________________________
Date of Most Recent Incident of Alleged Discrimination:
(Nonemployment 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
Religion Ancestry
Mental Disability
Race Sex/Gender (includes Harassment)
Color National Origin Retaliation**
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.)
Sexual Harassment
Discrimination
Unlawful Discrimination Complaint
2016/11 (W:forms)
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_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
What would you like the District to do as a result of your complaint -- what remedy
are you seeking? ___________________________________________________
_________________________________________________________________
_________________________________________________________________
The District shall document any and all complaints made by employees regarding
discrimination or harassment and maintain such records for a period of at least
five (5) years from the date of the complaint.
I certify that this information is correct to the best of my knowledge.
Signature of Complainant
Date
Send Original to the District,
Solano Community College District
Human Resources Office
4000 Suisun Valley Road
Fairfield, CA 94534
Or, you may send your Original complaint to:
Chancellor’s Office,
California Community Colleges
1102 Q Street
Sacramento, California 95811-6549
Attention:
Legal Affairs Division
click to sign
signature
click to edit
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