CALIFORNIA STATE UNIVERSITY, SAN BERNARDINO
PROCEDURE FOR A DISCRIMINATION
COMPLAINT BY A STUDENT
DISCRIMINATION COMPLAINT FORM
Student's Name
Telephone
Street
Address
City
Zip
Telephone Number
Email
Student's Statement
I am beginning the discrimination complaint process because of an action by
(University employee) which I describe below.
Student's Signature
Date
Attach extra pages if needed to fully describe and explain the following:
- Describe the complaint, provide relevant dates of events of the complaint and include
the names of all parties involved. Please attach extra pages if needed.
- Describe your proposed resolution, relief, or action sought.
- List or describe the University documents, records or materials which are relevant to
this complaint.
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The student delivers two completed copies of this page and attachments to the Vice
President for Student Affairs, UH room 231, 909-880-5185. The office signs below for
receipt of the form.
Received by Office of Vice President, Student Affairs
Date
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(Optional) I hereby authorize student members of the Discrimination Complaint
Hearing Panel to have access to information and materials contained in my complaint.
Student's Signature
Date
After the student has delivered a copy of the front page and attachments to the Vice
President for Student Affairs, the student begins the complaint process.
INFORMAL COMPLAINT PROCESS RESULTS
Date submitted for employee's review:
Results of the employee's review:
Review Date
Employee's Signature
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Date submitted for review by employee, his/her supervisor and the next level supervisor.
Results of that review:
Review Date
Next Level Supervisor's Signature
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REQUEST TO BEGIN FORMAL COMPLAINT PROCESS
(Student) I am requesting the initiation of the formal complaint process. I am
making the irrevocable choice between (check)
convening a Hearing Committee or (check)
making an in-person appeal through each administrative level up to the relevant Vice
President.
Student's Signature
Date
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FORMAL COMPLAINT PROCESS RESULTS
(To be completed by Office of the Vice President for Student Affairs)
Committee selection date:
Committee selected by:
Committee members and convener:
Hearing request denied or
approved. (Cite
reason if hearing is denied and inform next level supervisor):
Date of Hearing:
Committee Hearing results:
Date all parties were notified of results:
PROCEDURE FOR A DISCRIMINATION COMPLAINT BY A
STUDENT
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