Appendix D




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) (also under Title IX, 20 U.S.C. §§ 1681, et seq.)

    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.


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

                                               Title 5/EEO/ADA & Title IX Compliance Office

                                                50 Phelan Ave., B619

Unlaw Discr_App D                       San Francisco, CA 94112                                                6/06