CONFIDENTIAL EMPLOYMENT ENVIRONMENT FORM

The purpose of this form is to begin documenting Latino concerns you may have experienced personally or that you have witnessed. This information will be used to write a general report that will be addressed to the Chancellor. No specific names will be used unless you explicitly request that it be submitted to a particular office/departments of the University. These forms will also be filed with the office of affirmative action, which form is almost exactly alike except for a few details.

From:

Home Address:

Work Department:

1. Nature of Complaint. Please describe the situation.

x

x

x

x

x

x

x

2.Cause of complaint.

I think this situation has occurred because :

x

x

x

x

x

x

3. Remedy.

How I would like this situation to be corrected

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x

x

x

x

4. Witnesses

Other individuals I think you should speak with:

a)the person(s) accused of wrong-doing

x

x

b)Person(s) who have FIRST-HAND, direct knowledge.

x

x

x

x

I understand that this form will be used to write a general report on the status of Latinos and that if I want further action to be taken this form will be forwarded to the office of affirmative action.

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Signature........... Date