Attachment I

 

The Office of the Chief Diversity Officer and

Director of Equity and Access

Formal Complaint Form

for

Texas State UniversityĖSan Marcos

 

Instructions:

Texas State UniversityĖSan 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 No. 04.04.46) and Sexual Harassment (UPPS No. 04.04.42). In particular, you should review the information on the time limits as specified in the procedure. You must complete and submit this form within 90 workdays of the alleged incident. 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.

 

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 of Equity and Access, Texas State University-San Marcos, J.C. Kellam 840, 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:  Ā Texas State Student  Ā 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: ______________________________________________________

[Harassment (to include sexual harassment) or discrimination on the basis of your race, sex, sexual orientation, national origin, age, disability, veteransí status, color or religion.]

 

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

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

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

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

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

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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.

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

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

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

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13. If an advisor will assist you in the complaint process, indicate the individualís 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 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: _________________