Attachment I
Office of Equity and Access
for
Texas
State UniversitySan Marcos
Instructions:
Texas State UniversitySan Marcos is
committed to providing an educational and working environment that is free from
discrimination. This form is to be used for filing formal complaints under UPPS No.
04.04.46 and UPPS No. 04.04.42.
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) and Sexual Harassment and Sexual Misconduct (UPPS No.
04.04.42). In particular, you should review the information on the time
limits as specified in the procedure. It is a requirement that you use this
form in order to file a 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 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, 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. 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 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:
ˇ
Office of Equity and Access,
Texas State UniversitySan Marcos, J.C. Kellam 840, 601 University Drive, San
Marcos, TX 78666.
Name: ________________________________________________________________________
Last First
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)
Date
of incident of alleged discrimination: __________________________________________
Place
of incident of alleged discrimination: __________________________________________
Nature
of alleged discrimination: _________________________________________________
(Sexual
harassment, sexual misconduct, discrimination on the basis of your race, sex,
sexual orientation, national origin, age, disability, veterans status, color
or religion)
Describe
in detail the specific incident that is the basis of the alleged
discrimination: (Describe
each incident of harassment, misconduct, 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.)
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Did
the person you are complaining against state a reason for the action prompting
your complaint? If yes, please describe:
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Describe
why you believe the incident you described was related to your race, sex, or
whatever basis you indicated above.
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List
and describe all documents, e-mails, records, materials and other evidence
pertaining to your complaint:
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List
and identify all witnesses to the incidents or persons who have personal knowledge
of information pertaining to your complaint:
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Have you previously reported
or otherwise complained about this or related acts of harassment, misconduct,
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.
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Please
submit any additional information pertaining to the alleged discrimination:
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Describe
the injury or harm you suffered because of the alleged discrimination:
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What
would you like the University to do as a result of your complaint a what
remedy are you seeking:
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If
an advisor will assist you in the complaint process, indicate the individuals
name, title, address and telephone number:
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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 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: _________________