This form is to be submitted to one of the District’s Compliance Officers as a part of the formal procedure in order to initiate a complaint of alleged discrimination or harassment prohibited by the District’s Policy Against Unlawful Harassment (Including Sexual Harassment) and Discrimination of Employees (Policy No. 5010).
If you are more comfortable reporting your complaint verbally or in another manner, a Compliance Officer may complete this form for you and provide you with a copy.
You will not be retaliated against for filing a complaint.
COMPLAINANT INFORMATION
Name: _______________________________________________________
Address: _______________________________________________________ Phone: _______________
Email: _______________________________________________________
Job Title (if applicable): _______________________________________
Select Preferred Communication Method:
____ Email
____ Phone
____ In person
SUPERVISORY INFORMATION (if applicable)
Immediate Supervisor’s Name: _______________________________________________________
Title: _______________________________________
COMPLAINT INFORMATION
1.Your complaint of discrimination or harassment is made about:
Name: _______________________________________________________
Title: _______________________________________
Work Address: _______________________________________________________
Work Phone: _______________
Relationship to you:
_____ Supervisor
_____ Subordinate
_____ Co-Worker
_____ Other
2. Basis of discrimination and/or harassment (check as many as are applicable):
_____ Race
_____ Sex/Gender
_____ National Origin
_____ Religion
_____ Age
_____ Disability
_____ Sexual Orientation
_____ Marital Status
_____ Retaliation
_____ Other
3. Please describe what happened and how it is affecting you and your work. Please use additional sheets of paper if necessary and attach any relevant documents or evidence.
4. Date(s) harassment or discrimination occurred: _______________
Is the discrimination or harassment continuing? Circle one: Yes | No
5. Please list the name and contact information of any witnesses or individuals who may have
information related to your complaint:
6. Have you previously complained or provided information (verbal or written) about related
incidents? If yes, when and to whom did you complain or provide information?
7. If you have retained legal counsel and would like us to work with them, please provide their
contact information:
Signature: _______________________________________________________ Date: _______________
Adoption date: 4/27/09
Amended: 12/17/18