Complaint Form
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1
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3Executive Order 1096
Clear Form
Print Form
Revised June 23, 2015
Attachment A
COMPLAINT FORM
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.
Work Phone
CSU Campus
Cell Phone
Last Name
First Name
MI
Mailing Address
Home Phone
Best time to call:
AM/PM
City
E-mail
State
Zip Code
What is your relationship with the California State University campus listed above?
Current Employee?
Yes
No
Former a Employee?
Yes
No
Last Date of Employment
An applicant for employment?
Yes
No
A Third Party?
Yes
No
Please specify your relationship with the University:
Was Informal Resolution sought?
Yes
No
If yes, with whom:
Date
Indicate the type(s) of complaint being filed:
Discrimination
Harassment
Retaliation
Sexual Misconduct
Dating Violence
Domestic Violence
Stalking
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):
Race/Color
Religion
Sexual Orientation
Medical Condition
National Origin/Ancestry
Gender / Sex
Disability
Genetic Information
Gender Identity/Expression
Marital Status
Military/Veteran Status
Age
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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