Executive Order 1089
Attachment No. 1
COMPLAINT FORM FOR
Instructions: This complaint form is for use by individuals who are eligible to file a complaint of Discrimination, Harassment or Retaliation
under Executive Order 1089. Please fill in all of the information requested below as completely as possible and attach additional pages
to this form, if necessary. Please submit this form to [insert DHR Administrator's contact info.]
Leads, managers, or supervisors who receive this form should immediately forward it to [insert DHR Administrator's contact info.]
Best time to call:
What is your relationship with the California State University campus listed above?
Last Date of Employment
Former a Employee?
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):
If you are filing a Retaliation complaint, indicate the activity(ies) you engaged in that was/were the basis(es) for the alleged Retaliation.
Page 1 of 3