Attachment I

Texas State University

Office of the Chief Diversity Officer and

Director, Equity and Access

Formal Complaint Form

Instructions:

Texas State University 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 No. 04.04.46). In particular, you should review the information on the time limits as specified in the procedure. You must complete and submit this form as soon as possible following the alleged incident. By being as specific as possible when discussing incidents of discrimination, you will assist the investigators in the fact-gathering process. Be sure to include the dates the incidents occurred, the names of the persons involved and the names of those who may have witnessed the incident. Your complaint is not limited to the space provided. You are encouraged to attach additional materials that 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.

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 offenders, 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 complaints by mail or in person to:

The Office of the Chief Diversity Officer and Director, Equity and Access, Texas State University, J.C. Kellam 164, 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: ______________

I am a:  Texas State Student Texas State Employee  Other: ________________

I wish to complain against: ________________________________________________

(Identify the persons directly responsible for the alleged violation)

1. Date of alleged incident: _______________________________________________

2. Place of alleged incident: ______________________________________________

3. Nature of alleged incident: _____________________________________________

[Discrimination on the basis of your race, color, national origin, age, sex, religion, disability, veterans’ status, sexual orientation, gender identity, or expression.]

4. Describe in detail the specific incident that is the basis of the complaint: (Describe each incident of 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.)

___________________________________________________________________

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

___________________________________________________________________

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

___________________________________________________________________

7. List and describe all documents, emails, records, materials and other evidence pertaining to your complaint:

___________________________________________________________________

8. List and identify all witnesses to the incidents or persons who have personal knowledge of information pertaining to your complaint:

___________________________________________________________________

9. 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.

___________________________________________________________________

10. Describe the injury or harm you suffered because of the alleged incident:

___________________________________________________________________

11. Please submit any additional information pertaining to the alleged incident:

___________________________________________________________________

12. What would you like the university to do as a result of your complaint? What remedy you are seeking:

___________________________________________________________________

13. If an advisor will assist you in the complaint process (see Section 06.03 f.), 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 documentation such as emails, 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: _________________