Executive Order 1096
Revised June 23, 2015
Instructions: This complaint form is for use by individuals who are eligible to file a complaint of Discrimination, Harassment or Retaliation,
Sexual Misconduct, Dating or Domestic Violence or Stalking under under Executive Order 1096. Please fill in all of the information
requested below as completely as possible and attach additional pages to this form, if necessary.
Best time to call:
What is your relationship with the California State University campus listed above?
Former a Employee?
Last Date of Employment
An applicant for employment?
A Third Party?
Please specify your relationship with the University:
Was Informal Resolution sought?
If yes, with whom:
Indicate the type(s) of complaint being filed:
If you are filing a Discrimination or Harassment complaint, indicate the Protected Status(es) that was/were the basis(es) of the alleged
Discrimination or Harassment (Please select all that apply):
Gender / Sex
If you are filing a Retaliation complaint, indicate the activity(ies) you engaged in that was/were the basis(es) for the alleged Retaliation.
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