3 UNLAWFUL DISCRIMINATION COMPLAINT FORM UNLAWFUL DISCRIMINATION COMPLAINT FORM

Unlawful Discrimination Complaint Form

Name:

Last First

Address:

Street or P.O. Box City State Zip

Phone: Day ( ) Evening ( )

I Am A:  Student  Employee  Other:

I Wish To Complain Against:

District: College:

Date of Most Recent Incident of Alleged Discrimination:

(Employment complaints must be filed within 180 days of the date of the alleged unlawful discrimination occurred, except that this period should be extended by no more than 90 days following the expiration of the 180 days if the complainant first obtained knowledge of the facts of the alleged violation after the expiration of the 180 days.)

(Nonemployment complaints must be filed within one (1) year of the date of the alleged unlawful discrimination or within one (1) year of the date on which the complainant knew of should have known of the facts underlying the allegation of unlawful discrimination.)

I Allege Discrimination/and or Harassment Based on: (check only those which apply).

Complaints of discrimination on the bases listed in this box are protected under Title 5 and may also be filed with the State Chancellor’s Office.

The bases of discrimination in this box are not subject to the jurisdiction of the State Chancellor’s Office.

 Marital Status;  Gender Identity (includesTransgender, Questioning);

 Domestic Partner Status;  Medical Conditions;

 FMLA leave;  AIDS/HIV Status

You can mark any one or more of the 18 categories if you believe the treatment you received was the result of someone perceiving you to fit into one of the protected groups/categories.

H as informal resolution been attempted? Yes No Date Commenced: ____________________

Name of district officer involved in informal resolution: _______­­­­­_______________­­­­­­­______________

05-0282-002

Clearly state your complaint. Describe each incident of alleged discrimination separately. For each action 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 protected group status [religion, age, race, sex or whatever basis you indicated above] and/or, if applicable, why you believe you were retaliated against for filing of complaint or asserting your rights. (Attach additional pages as necessary.)

List the names, address and phone numbers of any person(s) who witnessed the incident or who are able to provide information about the complaint. (Attach additional pages as necessary.)

What would you like the District to do as a result of your complaint—what remedy are you seeking?