San José· Evergreen Community College
District
Human Resources
5/18/2016
Formal Discrimination Complaint Form
Completing the Formal
Discrimination Complaint Form
Any student or employee who believes they have
been subjected to discrimination on the basis of
their national origin, language/accent, disability
(physical or mental), religion, ancestry, race, age
(over 40), sexual orientation, color, immigration
status, veteran status, ethnic group identification,
marital status, gender identity, sex, medical
condition, or perceived to be in any of the above
protected category or associated with those in a
protected category, may complete this form to
seek redress.
Please note this form is fillable and should be type
written in adobe acrobat. The form can be
printed when completed and then e-mailed to
the appropriate Title IX Coordinator. Individuals
may also choose to print out the form and
complete it by hand with written attachments as
necessary. Once the form is completed it should
be submitted to Human Resources at the District
Office room 212.
1. Date- Make sure to date the form with the
date you submit the formal complaint to
Human Resources.
2. Complainant-This section is information from
the individual who is completing the form.
In most cases this should be the individual
who experienced the discriminatory action.
However, it is possible for a third-party to
submit a complaint on behalf of another
5/6/2016
person. Your full name with last name, first
name and middle name or initial should be
placed on the first line. Your position title or
student should be placed on the second
line. Next, select the designation that most
closely fits your association with San Jose
Evergreen Community College District.
Please note job applicants, vendors,
contractors or community members may
also file a formal complaint. You will need
to check the location where the
discrimination occurred.
3. Complaint is Filed Against- This space is for
you to identify (name) those individuals or
entities that subjected you to discrimination.
This may be an individual, several people
acting together, or a particular group
(examples: student club, academic division
or department, hiring committee, etc.) If
you have contact information for this
individual (address, cellphone number, or
e-mail address) this information should also
be provided.
Please be aware that SJECCD can only
investigate discriminatory acts against
people within its direct control (students,
faculty, or staff members) or those
contracted to perform services on its
properties. However, SJECCD will attempt
to provide alternative resources to
individuals experiencing discrimination from
other sources, please contact Human
Resources for further assistance.
4. Identification of dates, specific location,
activity or program in which the alleged
discrimination occurred- These three lines
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provided are for you to provide brief
summary information about the
discriminatory actions. Please add
additional pages as necessary.
5. Basis of Discrimination- Check every box
that you believe may apply to the
discriminatory actions you experienced.
Please review SJECCD Administrative Policy
3430 for guidance on these terms. Further
assistance regarding the meaning and
definitions of various types of discrimination
can be found at
https://www.eeoc.gov/laws/types/
6. Written statement-You can use the space
provided to provide a detailed explanation
of the harassment or discrimination you
experienced. Please feel free to attach
additional sheets as necessary to provide a
detailed explanation. The statement should
include responses to: who, what where,
when and how. This statement should
include any witnesses to each incident. If
more than one incident occurred, please
make sure to recount each incident of
harassment or discrimination that you
remember for the past year (if not
employment case) or 180 day (for
employment cases). Please note that
AP3435 restricts all complaint look back
periods to one year.
7. Informal Complaint Resolution- Please
attach a separate piece of paper to
explain the outcome regarding any
informal complaint procedure. If you have
previously engaged in the informal
complaint resolution process and were not
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satisfied with the outcome of that process,
please explain what occurred and why you
are filing a formal complaint. If you did not
previously engage in the informal
complaint procedure, please explain why
you believe that was not an appropriate
method to pursue.
8. Specific Action Requested- In this space
you should state either what remedy for
yourself you are seeking, or what sanction
\ disciplinary action you believe should be
imposed on the individual causing the
discrimination or harassment.
9. Signature- Please remember to sign the
complaint. Complaints received without a
signature will be retuned with a request to
sign before being deemed officially filed.
10. Contact Information of Complainant- At the
bottom of page two, please provide your
name, address, and at least one phone
number. If you prefer to be contacted by
e-mail, please use the second telephone
number spot to place your e-mail address.
Please feel free to place a * (star) by the
contact method you prefer.
11. Witness information- On page 3 please
identify any witnesses to the discrimination/
harassment. Please provide as much
contact information (name, address,
telephone and e-mail) as you know for
each witness. If there are more than three
witnesses, please use additional sheets to
continue identifying witnesses.
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Document Hyperlink: Formal Complaint
Lisa Owen
HR Analyst
lisa.owen@sjeccd.edu
408.274.6700 ext. 6586
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