DISCRIMINATION/SEXUAL HARASSMENT

Discrimination/Sexual Harassment

Formal Complaint Form

for

Texas State University–San Marcos

Instructions:

Texas State University–San Marcos is committed to providing an educational and working environment that is free from discrimination. Prior to completing this form, it is important for you to be fully aware of the specific complaint procedures outlined in the policy on Discrimination (UPPS 04.04.46) and/or Sexual Harassment (UPPS 04.04.42). In particular, you should review the information on the time limits as specified in the procedure. It is not a requirement that you use this form in order to file a complaint. If you do choose to use this form, please include all the information requested below in your complaint. By being as specific as possible when discussing incidents of harassment or discrimination, you will assist the investigators in the fact-gathering process. Be sure to include the date(s) the incident(s) occurred, the name(s) of the person(s) involved and the name(s) of those who may have witnessed the incident. Your complaint is not limited to the space provided. You are encouraged to attach additional materials, which may assist in the investigation process. Please note that information provided on this or any other form is not considered an official complaint unless it is signed by you and dated. Discrimination complaints may not be submitted by e-mail.

Upon receipt of your complaint, the University will review it. If it is determined that your complaint is complete and raises covered issues, an investigation will be initiated. You will be informed of the outcome of the investigation.

To investigate your complaint, it will be necessary to interview you, the alleged offender(s), and any witnesses with knowledge of the allegations or defenses. The University will notify all persons involved in the investigation that it is confidential and that unauthorized disclosures of information concerning the investigation could result in disciplinary action.

It is the expectation of the University that those who file a complaint will remain active and cooperative in the investigation process.

Submit Discrimination/Sexual Harassment Complaints by mail or in person to:

· Office of Equity and Access, Texas State University – San Marcos, J.C. Kellam 1080, 601 University Drive, San Marcos, TX 78666.

Name: ________________________________________________________________________

Last First

Address: ______________________________________________________________________

Street or P.O. Box City State Zip

Phone: Day _____________________________ Evening _______________________________

E-mail Address: ________________________________________________________________

Texas State Dept: ___________________ Texas State ID or Social Security: ______________

I Am A: Texas State Student Texas State Employee † Other: _____________________

I Wish To Complain Against: ____________________________________________________

(Identify the person(s) directly responsible for the alleged violation)

Date of incident of alleged discrimination: __________________________________________

Place of incident of alleged discrimination: _________________________________________

Nature of alleged discrimination: _________________________________________________

(Sexual harassment; discrimination on the basis of your race, sex, sexual orientation, national origin, age, disability, color or religion.

Describe in detail the specific incident that is the basis of the alleged discrimination: (Describe each incident of harassment or discrimination separately. Please be as detailed as possible, giving names, dates and places; include phone numbers and addresses if possible. Use additional paper if needed.)

______________________________________________________________________________

Did the person you are complaining against state a reason for the action prompting your complaint? If yes, please describe:

______________________________________________________________________________

Describe why you believe the incident you described was related to your race, sex, or whatever basis you indicated above.

______________________________________________________________________________

List and describe all documents, e-mails, records, materials and other evidence pertaining to your complaint:

______________________________________________________________________________

List and identify all witnesses to the incident(s) or persons who have personal knowledge of information pertaining to your complaint:

______________________________________________________________________________

Have you previously reported or otherwise complained about this or related acts of harassment or discrimination to a University supervisor or official? If so, please identify the individual to whom you made the report, the date you made the report and the resolution.

______________________________________________________________________________

____________________________________________________________________

Please submit any additional information pertaining to the alleged discrimination:

______________________________________________________________________________

Describe the injury or harm you suffered because of the alleged discrimination:

______________________________________________________________________________

What would you like the University to do as a result of your complaint -- what remedy are you seeking:

______________________________________________________________________________

If an advisor will assist you in the complaint process, indicate the individual’s name, title, address and telephone number:

______________________________________________________________________________

Complaint Acknowledgment:

I certify that to the best of my knowledge the information that I have provided is accurate and the events and circumstances are as I have described them.

I understand and acknowledge that a copy of this complaint, along with the attachments, will be furnished to the alleged offender (“respondent”). I have attached to this complaint any supportive evidence and/or documentation such as e-mails, records, materials which I believe support my allegation. I also understand and consent to the disclosure of information contained in this complaint to appropriate administrators and witnesses interviewed for the purpose of investigating this complaint. I understand that I will have to provide contact information of witnesses identified in this complaint. I am willing to cooperate fully in the investigation and provide whatever evidence the University deems relevant.

I understand that the nature of this complaint, correspondence, and all discussions conducted in the course of investigation of the information contained in this complaint are confidential to the extent permitted by law and unauthorized disclosures of information concerning the investigation could result in disciplinary action. I agree to abide by these guidelines.

Signature: _______________________________ Date: _________________

Please note: If you indicate you will be assisted by an advisor, your signature below authorizes the named individual to receive copies of relevant student records and correspondence regarding the complaint and to accompany you to any meetings.

Signature: _______________________________ Date: _________________