Appendix D

UNLAWFUL DISCRIMINATION FORMAL COMPLAINT FORM

Name: ____________________________________________________________________________

(Last) (First)

Address: _________________________________________________________________________

Street or P.O. Box City State Zip

Phone: Day ( ) __________________________ Evening ( ) _____________________

I am a: Student/ID#_________________ Employee Other _______________________

Individual(s)I wish to complain against: ______________________________________________

District: ____________________________________________________________________

Date of Most Recent Incident of Alleged Discrimination:________________________________

(Nonemployment complaints must be filed within one year of the date of the alleged unlawful discrimination. Employment complaints must be filed within six months of the date of the alleged unlawful discrminination.)

I Allege Discrimination Based on the Following Category Protected under Title 5 (you must select at least one):

Ethnic Group Identification Religion Color Age National Origin Race Ancestry

Physical/Mental Disability Sex/Gender (Includes Gender Identity & Harassment)

Sexual Orientation (includes Gay, Lesbian, Bisexual) Retaliation**

Perceived to be in protected category or associated with those in protected category =========================================================================

Marital Status Transgender, Questioning Domestic Partner Status

Medical Conditions Vietnam-Era Veteran Status AIDS/HIV Status

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

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Clearly state your complaint. Describe each incident of alleged discrimination separately. For each incident 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 your religion, age, race, sex or whatever basis you indicated above. **If applicable, explain why you believe you were retaliated against for filing a complaint or asserting your right to be free from discrimination on any of the above grounds. (Attach additional pages as necessary.) _________________________________________________________________________________________

___________________________________________________________________________________________________

__________________________________________________________________________________________________

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

___________________________________________________________________________________________________

I certify that this information is correct to the best of my knowledge.

__________________________________________ __________________

Signature of Complainant Date

Send Original to the District: San Francisco Community College District

Affirmative Action Office

31 Gough Street, Room 16

Unlaw Discr_App D San Francisco, CA 94103 6/06