Printable Employee Discrimination Harassment Coplaint Form Download - Free Download
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& HARASSMENT COMPLAINT FORM
Office for Equal Opportunity | One Washington Square | San José, CA 95192-0046 | 408-924-2250 408-924-1784 (fax)
EMPLOYEE DISCRIMINATION & HARASSMENT COMPLAINT FORM
Instructions: Please print using blue or black ink pen. Fill out all of the information requested below as completely as
possible. Return completed and signed form to the Office for Equal Opportunity, 0046.
Campus Phone: Home Phone:
Status: (check one) SJSU Employee: SJSU Applicant: SJSU Student:
If you are an employee, what is your title/classification If you are a student, what is your date of last registration
Indicate the ground(s) on which you are making your complaint of discrimination/harassment.
Sex Race Religion
Gender Identity Color Disability
Sexual Orientation National Origin Medical Condition
Marital Status Ancestry Veteran Status
Age Citizenship Status
Nondiscrimination Act (GINA)
Retaliation (Please indicate the type of retaliation by checking the applicable box(es) above.)
Identify the dates that the alleged discrimination took place:
Earliest date: Latest date:
1. Identify the person or persons against whom your allegations are made, their working relationship to you (supervisor,
professor, co-worker, student, etc…) and their work or classroom location:
SJSU HR: revised 08/19/2011 Page 1 of 3