Complaint Form For Discrimination/harassment/retaliation Complaints
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1
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3Executive Order 1089
Clear Form
Print Form
Attachment No. 1
COMPLAINT FORM FOR
DISCRIMINATION/HARASSMENT/RETALIATION COMPLAINTS
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.]
CSU Campus
Department
Last Name
First Name
MI
Mailing Address
City
State
Zip Code
E-mail
Home Phone
Work Phone
Mobile Phone
Best time to call:
AM/PM
What is your relationship with the California State University campus listed above?
Last Date of Employment
Current Employee?
Yes
No
Former a Employee?
Yes
No
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
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
Disability
Genetic Information
Gender Identity/Expression
Marital Status
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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