Discrimination, Harassment & Retaliation Intake Form

Please note that submissions using this form might not be reviewed outside of normal business hours. If there is an immediate risk to health or safety, please call 911 or University Police at 657-278-2515.

The CSU prohibits discrimination, harassment, sexual misconduct, dating and domestic violence, and stalking. Such behavior violates University policy and may also violate state or federal law. This form should be used to report an incident involving discrimination, harassment, or retaliation. CSU Policy Prohibiting Discrimination, Harassment, Sexual Misconduct, Sexual Exploitation, Dating Violence, Domestic Violence, Stalking, and Retaliation (Nondiscrimination Policy) provides definitions and a detailed explanation of the policy and complaint process.

Incidents involving gender-based discrimination, gender-based harassment, sexual misconduct, stalking, dating and domestic violence and/or a violation of University policy regarding consensual relationships should be directed to the Title IX Coordinator.

Please note this form is not confidential. Those seeking to discuss a concern while maintaining confidence to the greatest extent possible should contact Blair Miles to discuss options at 657-278-4933 or bmiles@fullerton.edu.

Involved Parties/Witnesses

Please list the individuals involved (excluding yourself). Include as many of the listed fields as you provide.

Name of Individual or Organization:

Select Role:

Other Details:

Phone Number (if known):

Email Address (if known):

Information About the Incident

* Please provide a detailed description of the incident(s) and be sure to include as much information as possible.

Describe the specific harm you have suffered resulting from the incident(s).

If you are filing a retaliation complaint, indicate the activity(ies) you engaged in that was/were the basis(es) for the alleged allegation.

Describe the outcome(s) you expect from filing your complaint. Be as specific as possible.

Was this incident reported to law enforcement?
Yes
No

Supporting Documentation

Please note there is a 15MB file limit. If the file you wish to upload exceeds 15MB, please contact Blair Miles to discuss options at 657-278-4933 or bmiles@fullerton.edu.

Photos, video, email, and other supporting documents may be attached below.

Discrimination, Harassment & Retaliation Misconduct Reporting Form

Web Accessibility