Complaint Form
Please correct the following error(s):
I have reviewed Chancellor’s Regulation A-830.
Click here for Chancellor’s Regulation A-830.
Complainant Category
Select a Category
DOE Employee
Non-DOE Employee
Parent/Guardian
Student
Applicant for Employment
The Complainant is the person who is reporting the allegation(s)
Complainant Information
Complainant First Name
Complainant Last Name
If you are a parent, type student's first and last name (otherwise leave blank):
Student's First Name
Student's Last Name
Complainant Email
Note: This must be your valid email address or you will not be able to submit this complaint
Job Title
(If an employee, please provide Job Title, otherwise leave blank)
Home Address
City
State
Zip
Country
Preferred Contact Method
Select a Contact Method
Home Phone
Work Phone
Mobile Phone
Email
Home Phone
Work Phone
Mobile Phone
Victim Information
Click here if you are reporting the allegation and are also the victim of the alleged discrimination.
Victim First Name
Victim Last Name
Victim Type
Complaint Request
This is a request to OEO for a formal investigation of a complaint of alleged discrimination.
First Name of Principal or Head of Site
Last Name of Principal or Head of Site
Title
School/Office/Region
Site Address
Site Phone
Nature of Complaint
1. Check below why you were discriminated against
Age
Alienage/Citizenship
Arrest/Conviction
Color
Creed
Disability
Ethnicity/National Origin
Gender/Sex
Marital Status
Military Status
Partnership Status
Predisposing Genetic Characteristic
Race
Religion
Retaliation (for complaint)
Sexual Harassment
Sexual Offense and Stalking
Sexual Orientation
Status as a Victim of Domestic Violence
Weight (for students only)
2. Name/Title of Person(s) that allegedly committed the act(s) of discrimination
Add New Person
ID
Temp ID
Title
First Name
Last Name
Action
3. Name/Title of Person(s) that witnessed the act(s) of discrimination
Add New Witness
ID
Temp ID
Type
Title
First Name
Last Name
Action
4. Where did it take place: (Please provide site name & address)
(Maximum 2,000 characters)
5. Date(s) on which alleged act(s) of discrimination occurred
(MM/DD/YYYY - Please separate multiple dates with commas. Maximum of 50 characters)
6. Explain what happened
(Maximum 2,000 characters)
7. What relief or corrective action are you seeking?
(Maximum 2,000 characters)
Send paper copies of any documents that you want to support this complaint so that we receive them within five working days of the date when you complete this form. Failure to submit timely supporting documentation may delay our response.
Once you submit this complaint, please check your email for email confirmation.
Submit
The Date(s) on which alleged act(s) of discrimination occurred is not valid.
The Name/Title of Person(s) that allegedly committed the act(s) of discrimination field is required
The Name/Title of Person(s) that witnessed the discrimination field is required
Please enter at least one phone number in the Home Phone, Work Phone or Mobile Phone fields
