State of california department of corrections and rehabilitation discrimination complaint




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STATE OF CALIFORNIA DEPARTMENT OF CORRECTIONS AND REHABILITATION

DISCRIMINATION COMPLAINT

CDCR 693 (REV. 06/10)




Page 1 of [    ]



Please See Instructions on Last Page

I. COMPLAINANT INFORMATION

When Complainant is filing a third party complaint (The Complainant is NOT directly subjected to the alleged discrimination), Section III (THIRD PARTY COMPLAINT INFORMATION) MUST be completed.

Please check one current employment status from the following and complete the contact information below:

a. Current CDCR Employee:  Permanent Employee  Limited-Term or Temporary Employee (e.g., Student Assistant, Retired Annuitant)

b. Contractor:  Registry  Other

c.  Former CDCR Employee

d.  Job Applicant

e.  Other State Department/Agency Employee (Department/Agency Name)      .

f.  Other (Specify)      .




COMPLAINANT'S PERSONNEL ID (UP TO 8 DIGITS) Effective when assigned with BIS' implementation

     


LAST 4 DIGITS SOCIAL SECURITY NUMBER

     


COMPLAINANT'S NAME (Last)

     


(First)

     



(M.I.)

     


DIVISION/OFFICE

     


SUB-DIVISION/OFFICE (if applicable)

     


INSTITUTION/PAROLE REGION/OFFICE LOCATION

     


SPB CLASSIFICATION (e.g., SSM I, AGPA, Correctional Officer)

     


JOB TITLE OTHER THAN SPB CLASSIFICATION (if applicable)

     


MAILING ADDRESS (Street/PO Box) Required

     


HOME TELEPHONE NUMBER

     


(City)

     


(State)

     


(Zip Code)

     


PERSONAL E-MAIL ADDRESS (Optional)

     


WORK ADDRESS (Street/PO Box)

     


WORK TELEPHONE NUMBER

     


(City)

     


(State)

     


(Zip Code)

     


WORK E-MAIL ADDRESS

     


ALTERNATE TELEPHONE NUMBER

     


PREFERRED WAY TO BE CONTACTED

1.      


2.      



WORK SCHEDULE/REGULAR DAYS OFF

     


GENDER

 Male


 Female

AGE GROUP

 Under 40

 40 and Over


ETHNICITY

 American Indian or Alaskan Native  Asian  Black

 Filipino  Hispanic  Pacific Islander  White

 Other (Specify)      .



II. RELATED COMPLAINT FILING INFORMATION

Have you filed this discrimination complaint with another agency/entity?

 Yes  No

If "Yes," please check appropriate box(es) below:




 EEOC (Date:      )

 DFEH (Date:      )

 SPB (Date:      )

 Worker’s Comp. (Date:      )

 Labor Relations (Grievance) (Date:      )

 Other (Specify:      ) (Date:      )

SIGNATURES -- Please Read Before Signing

I declare under penalty of perjury and the laws of the State of California that the information I have entered on this discrimination complaint is true and complete to the best of my knowledge. I have read the contents of this form including the instructions, and I agree to cooperate fully with any investigation conducted by the California Department of Corrections and Rehabilitation (CDCR), Office of Civil Rights (OCR), pertaining to this discrimination complaint. I also agree to advise OCR of any changes in my contact information.

COMPLAINANT'S SIGNATURE


DATE SIGNED

     


EEO COORDINATOR'S SIGNATURE (Optional)


DATE SIGNED

     


Page 2 of [    ]



III. THIRD PARTY COMPLAINT INFORMATION

1. Are/were you (as the Complainant) directly subjected to the alleged discrimination?  Yes  No

If "No," please answer Question 2. If "Yes," skip the following sections and go to Section IV (RESPONDENT INFORMATION).

2. Do you know who is/was directly subjected to the alleged discrimination?  Yes  No



If "Yes," please answer Question 3 and complete the following sections below. If "No," skip the following sections and go to Section IV (RESPONDENT INFORMATION).

3. How many individuals are/were directly subjected to the alleged discrimination?      

If there is more than one individual, please complete this page for each individual to the best of your knowledge.

Please check one current employment status for the individual directly subjected to the alleged discrimination from the following and complete the sections below:

a.

b.

c.

d.

e.

f.


Current CDCR Employee:  Permanent Employee  Limited-Term or Temporary Employee (e.g., Student Assistant, Retired Annuitant)

Contractor:  Registry  Other

 Former CDCR Employee

 Job Applicant

 Other State Department/Agency Employee (Department/Agency Name)      .

 Other (Specify)      .


NAME (Last)

     


(First)

     

(M.I.)

     

DIVISION/OFFICE

     


SUB-DIVISION/OFFICE (if applicable)

     


INSTITUTION/PAROLE REGION/OFFICE LOCATION

     


SPB CLASSIFICATION (e.g., SSM I, AGPA, Correctional Officer)

     


JOB TITLE OTHER THAN SPB CLASSIFICATION (if applicable)

     


WORK ADDRESS (Street/PO Box)

     


WORK TELEPHONE NUMBER

     


(City)

     


(State)

     


(Zip Code)

     


WORK E-MAIL ADDRESS

     


WORK SCHEDULE/REGULAR DAYS OFF

     


GENDER

 Male


 Female

AGE GROUP

 Under 40

 40 and Over


ETHNICITY

 American Indian or Alaskan Native  Asian  Black

 Filipino  Hispanic  Pacific Islander  White

 Other (Specify)      .



OCR USE ONLY -- Do Not Use the Space Below

P


age 3 of [    ]

IV. RESPONDENT INFORMATION Total number of Respondent(s) included in this Discrimination Complaint:      

RESPONDENT #:       -- Please complete this page for each Respondent to the best of your knowledge.

Respondent:  Individual  Other
If "Individual," please check one current employment status from the following and complete all sections. If "Other," skip the following sections and go to Section V (COMPLAINT INFORMATION).




a.

b.

c.

d.

e.

Current CDCR Employee:  Permanent Employee  Limited-Term or Temporary Employee (e.g., Student Assistant, Retired Annuitant)

Contractor:  Registry  Other

 Former CDCR Employee

 Other State Department/Agency Employee (Department/Agency Name)      .

 Other (Specify)      .



RESPONDENT’S NAME (Last)

     


(First)

     



(M.I.)

     


DIVISION/OFFICE

     


SUB-DIVISION/OFFICE (if applicable)

     


INSTITUTION/PAROLE REGION/OFFICE LOCATION

     


SPB CLASSIFICATION (e.g., SSM I, AGPA, Correctional Officer)

     


JOB TITLE OTHER THAN SPB CLASSIFICATION (if applicable)

     


WORK ADDRESS (Street/PO Box)

     


WORK TELEPHONE NUMBER

     


CITY

     


STATE

     


ZIP CODE

     


WORK E-MAIL ADDRESS

     


WORK SCHEDULE/REGULAR DAYS OFF

     


GENDER

AGE GROUP

ETHNICITY






Male

Female







Under 40

40 and Over











American Indian or Alaskan Native  Asian  Black

Filipino  Hispanic  Pacific Islander  White

Other (Specify)      .


PROFESSIONAL RELATIONSHIP TO THE COMPLAINANT (at the time the alleged discrimination took place)

 Supervisor (Direct)  Supervisor (Indirect)  Coworker  Subordinate  Other (Specify)      .



PERSONAL RELATIONSHIP TO THE COMPLAINANT

Have you had a personal relationship with the Respondent?  Yes  No



If “Yes,” please specify the type of personal relationship.      .

OCR USE ONLY -- Do Not Use the Space Below




Page 4 of [    ]

V. COMPLAINT (ALLEGATION) INFORMATION Total Number of allegation(s) included in this Discrimination Complaint:      

ALLEGATION #:       -- Please complete this page and the next page for each allegation.

a. Description of discrimination (allegation) (Who, what, where, when, how, and why you believe that you are/were discriminated.)

     




b. Basis of alleged discrimination (What you believe the alleged discrimination is based on) – See instructions for additional information.



Age (40 or older)



Ancestry (Specify ancestry)      .



Color



Disability (Physical or mental)



Genetic Information



Marital Status (Specify marital status)      .



Medical Condition (Cancer or genetic characteristics)



National Origin (Specify nationality)      .



Political Affiliation (Specify)      . (Union or Collective Bargaining issues are NOT included)



Race



Religion (Specify religion)      .



Sex (Specify category)  Gender  Sexual Harassment  Pregnancy



Sexual Orientation



Veteran Status/Military Service (Specify the period of military service)      .



Violation of Leave Rights under the Family and Medical Leave Act and/or California Family Rights Act (FMLA/CFRA)



Other (Specify)      .

In addition to the basis of alleged discrimination listed above, all employees are protected from retaliation due to his or her protected activity.



Retaliation

c. Type of harm/issue caused by alleged discrimination



Failure to Appoint  Failure to Accommodate  Demotion  Harassment



Failure to Promote  Denied Leave  Termination



Job Duty Change/Transfer  Working Conditions  Retaliation



Hostile Work Environment  Other (Specify)      .

d. Respondent(s) associated with this allegation (Indicate Respondent # and Name, e.g., Respondent #1/Smith)

     


e. What was the date of the last discriminatory action? (for this allegation)

     


f. Was the discriminatory action ongoing? If “Yes,” what was the date of the first discriminatory action? (for this allegation)

 Yes (Date:      )  No






Page 5 of [  ]



ALLEGATION #:       (Continued)




g. Did you or anyone report the allegation to any supervisor/manager, EEO Counselor, EEO Coordinator, hiring authority, or OCR, prior to filing this complaint?  Yes  No

If “Yes,” to whom was the allegation reported?      .



1. NAME (Last)

     


(First)

     


DATE REPORTED

     


JOB TITLE

     


ACTION TAKEN

     


2. NAME (Last)

     


(First)

     


DATE REPORTED

     


JOB TITLE

     


ACTION TAKEN

     


3. NAME (Last)

     


(First)

     


DATE REPORTED

     


JOB TITLE

     


ACTION TAKEN

     


h. Do you have any evidence to support this allegation?  Yes  No

If “Yes,” complete the following:



1. Evidence Description (What kind of evidence, etc.)

     



2. Evidence Description

     




3. Evidence Description

     



i. Do you have any witness(es) who can provide information (first hand knowledge) related to this allegation?  Yes  No

If “Yes,” complete the following:



1. WITNESS NAME (Last)

     


(First)

     


RELATIONSHIP

     


INFORMATION HE OR SHE CAN PROVIDE

     


2. WITNESS NAME (Last)

     


(First)

     


RELATIONSHIP

     


INFORMATION HE OR SHE CAN PROVIDE

     


3. WITNESS NAME (Last)

     


(First)

     


RELATIONSHIP

     


INFORMATION HE OR SHE CAN PROVIDE

     



Page 6 of [    ]

VI. REMEDY REQUESTED

What remedy are your requesting?

     





Are you willing to participate in mediation?  Yes  No

ADDITIONAL COMMENTS

     

Submission Information – Do Not Use the Space Below

Date Entered into CMS by:

NAME


DATE


PHONE NUMBER


CDCR 693 Information and Instructions

The California Department of Corrections and Rehabilitation (CDCR) is committed to providing a workplace in which all individuals are treated with respect and professionalism. It is the policy of CDCR, as required by federal and State laws, to provide a work environment free of discrimination. The Department’s Equal Employment Opportunity (EEO) and Sexual Harassment (SH) policies are found in the Department Operations Manual, Chapter 3, Article 1 (31010). The CDCR 693, Discrimination Complaint Form, may be used by a current or former CDCR employee, or a job applicant applying for a position within CDCR to record and report possible discrimination. However, you are not required to complete the form in order to file a discrimination complaint. A discrimination complaint must be filed with the CDCR within one year (365 days) from the last act of discrimination.

Employees and job applicants are also entitled to file a charge of discrimination with the U. S. Equal Employment Opportunity Commission (EEOC) and/or California Department of Fair Employment and Housing (DFEH). You must file a discrimination complaint within 300 days from the date of the alleged violation with the EEOC and/or within one year with the DFEH. Discrimination complaints filed with CDCR may be appealed to and/or heard by the State Personnel Board (SPB) by filing an appeal within 30 days of your receipt of the Department’s final determination.

Please identify the basis of discrimination (circumstances of alleged discrimination) from the list of the protected groups below. An individual filing a complaint will also need to identify the harm/issue that he or she believes was caused by the alleged discrimination (i.e., you were adversely affected with respect to any compensation, condition, privilege, or term of employment). In addition, a connection (nexus) between the alleged basis and the alleged harm/issue needs to be present. The definition of each protected group is as follows:


Definition

Age The chronological age of any individual who has reached his or her 40th birthday.

Ancestry The national or cultural origin of a line of familial descent.

Color The color of skin of an individual, including shades of skin within a racial group.

Disability A physical or mental impairment affecting one or more body systems which limits a major life activity, including work; a record of such an impairment; or being regarded as having such an impairment. This includes HIV and AIDS.

Genetic Information Information about an individual’s genetic tests and the genetic tests of an individual’s family members, as well as information about any disease, disorder, or condition of an individual’s family members (i.e., an individual’s family medical history).

Marital Status The legal status in a relationship such as married, never married, single, separated, divorced, or widowed.

Medical Condition A person’s genetic characteristics or a person who has or had cancer.

National Origin An individual’s or his/her ancestor’s place of origin. An individual’s common language, culture, ancestry, and other similar social characteristics.

Political Affiliation Membership or association in a political party or special interest group (Union issues are NOT included).

Race An individual’s belonging to one of the accepted anthropological racial groups (i.e., Caucasian, African, Aborigine, or Asian) or the perception that a person is a member of a racial group.

Religion A person’s sincerely held religious belief or belonging to an organized religion or sect.

Sex A person’s gender or gender identity such as male, female, transgender, or transsexual. This protected group includes sexual harassment, pregnancy, childbirth, or medical conditions related to pregnancy or childbirth.

Sexual Harassment Unsolicited and unwelcome sexual advances, requests for sexual favors, and other verbal, physical, or visual conduct of a sexual nature that interferes with work performance by creating an intimidating, hostile, or offensive work environment.

Sexual Orientation The direction of person’s sexual attention and/or physical attraction and preference (heterosexuality, homosexuality, bisexuality).

Veteran Status/Military Service Vietnam Era veterans who served from August 5, 1964, to May 7, 1975, and any person entitled to the rights and benefits under the Uniformed Services Employment and Reemployment Rights Act (USERRA).

Violation of Leave Rights under Provisions in State and federal statutes that allow for up to 12 weeks of unpaid leave for the birth of a the Family Medical Leave Act child for purposes of bonding, placement of a child in the employee’s family for adoption or foster (FMLA) and/or California Family care, and the qualified serious health condition of the employee or the qualified serious health Rights Act (CFRA) condition of a parent, spouse, or child. California law provides the same protection for registered domestic partners.

In addition to the list of the protected groups above, all employees are also protected from retaliation.



Retaliation A negative employment action taken against an individual due to his or her protected activity (e.g., opposition to a discriminatory practice or participation in the discrimination complaint process). Whistleblower complaints are NOT included.

Please submit a completed Discrimination Complaint (CDCR 693) to an EEO Coordinator or the Office of Civil Rights (OCR). If you have any questions or concerns about filing a discrimination complaint, please contact the OCR at the following locations:


Headquarters: California Department of Corrections and Rehabilitation

Office of Civil Rights

P O Box 942883

Sacramento, CA 94283-0001

Phone: (916) 324-1923

Fax: (916) 445-0583



Regional Offices: Office of Civil Rights Office of Civil Rights Office of Civil Rights

Northern Region (Sacramento) Central Region (Bakersfield) Southern Region (Rancho Cucamonga)

1515 S St. Ste. 100S 4900 California Ave. Ste. 110-B 10350 Commerce Center Dr. Ste. 250

Sacramento, CA 95811-7259 Bakersfield, CA 93309-7024 Rancho Cucamonga, CA 91730-5863

Phone: (916) 324-1923 Phone: (661) 863-6658 Phone: (909) 483-8289

Fax: (916) 445-0583 Fax: (661) 863-6650 Fax: (909) 483-8276


EEO/SEXUAL HARASSMENT HOTLINE TELEPHONE NUMBER:

1-800-272-1408

I. COMPLAINANT INFORMATION

Definition of Complainant: A person who files a complaint on his or her behalf or files on behalf of another, regarding a violation of the Department’s EEO and SH policy. A Complainant may be a current or former CDCR employee, or a job applicant applying for a position within CDCR.

Please indicate your current employment status and complete the following contact information to the best of your knowledge. Please note that OCR may not have jurisdiction to investigate a complaint filed by a Complainant who is other than a current or former CDCR employee or a job applicant.



a. Current CDCR Employee: If you are a current CDCR employee, please identify yourself as either “Permanent Employee” or “Limited-Term or Temporary Employee.” For example, a Student Assistant and a Retired Annuitant are considered as Temporary Employees.

b. Contractor: If you are not a CDCR employee, but currently work for CDCR as a contractor, please identify yourself as “Registry” or “Other” type of contractor.

c. Former CDCR Employee: Please check this box if you are not a current CDCR employee but formerly employed by CDCR. For example, a retired employee. Please note that a discrimination complaint must be filed within one year from the last act of discrimination.

d. Job Applicant: Please check this box if you are not a current CDCR employee but a job applicant.

e. Other State Department/Agency Employee: If you are employed by a State Department or Agency other than CDCR, check this box and indicate the name of the Department or Agency. Please note that OCR may not have jurisdiction to investigate your discrimination complaint.

f. Other: If none of the above applies to you, check this box and indicate your employment status.

COMPLAINANT’S PERSONNEL ID: Please provide your Personnel ID (up to 8 digits) assigned by the Department. Please disregard this section if a Personnel ID has not been assigned to you. Please note that a Personnel ID is NOT a position number.

LAST 4 DIGITS SOCIAL SECURITY NUMBER: Please provide the last 4 digits of your social security number.

COMPLAINANT’S NAME: Please do NOT use initials (except middle name) or nickname.

DIVISION/OFFICE: Please select one Division or Office from the following:

  • Adult Operations*

  • Office of Internal Affairs

  • Office of Victim and Survivor Rights and Services

  • Adult Programs*

  • Office of Research

  • Facility Planning, Construction & Management*

  • Division of Juvenile Justice*

  • Office of the Ombudsman

  • Office of Audits and Compliance

  • Office of the Legislation

  • Office of Public and Employee Communications

  • Prison Industry Authority

  • Office of Legal Affairs

  • Division of Correctional Health Care Services

  • Division of Support Services*

  • Board of Parole Hearings (Adult)

  • California Prison Health Care Services

  • Enterprise Information Services

  • Corrections Standard Authority




  • Office of Labor Relations

  • Executive Office




SUB-DIVISION/OFFICE: Please leave this section blank if not applicable. The name of the Sub-Division or Office is required if your DIVISION/OFFICE is listed above with an asterisk (*).

INSTITUTION/PAROLE REGION/OFFICE LOCATION: Please indicate where your work site is located.

Example 1 Example 2

DIVISION/OFFICE: Adult Operations DIVISION/OFFICE: Adult Operations

SUB-DIVISION/OFFICE: Division of Adult Institutions SUB-DIVISION/OFFICE: Division of Adult Parole Operations

INSTITUTION/PAROLE REGION/OFFICE LOCATION: Avenal State Prison INSTITUTION/PAROLE REGION/OFFICE LOCATION: Region II



Example 3 Example 4

DIVISION/OFFICE: Division of Juvenile Justice DIVISION/OFFICE: Office of Internal Affairs

SUB-DIVISION/OFFICE: Division of Juvenile Facilities SUB-DIVISION/OFFICE: N/A (Leave this section blank)

INSTITUTION/PAROLE REGION/OFFICE LOCATION: Ventura YCF INSTITUTION/PAROLE REGION/OFFICE LOCATION: Central Region



SPB CLASSIFICATION: If you are a current CDCR employee, please indicate your SPB Classification, for example, Staff Services Manager I, Associate Governmental Program Analyst, Correctional Officer, Correctional Administrator, Supervisor of Correctional Education Programs, etc.

JOB TITLE OTHER THAN SPB CLASSIFICATION: If you are a current CDCR employee and have a job title other than SPB Classification, please indicate the job title, for example, Regional Manager, Range Sergeant, IST Lieutenant, Associate Warden, Principal, etc. If you are NOT a current CDCR employee, please indicate your job title here, for example, Vocational Nurse.

MAILING ADDRESS: Please provide your personal mailing address, including street name (or Post Office Box), City, State, and Zip code. Please do NOT use “On File.”

WORK ADDRESS: Please provide your work address, including street name (or Post Office Box), City, State, and Zip code.

HOME TELEPHONE NUMBER: Please provide your home phone number.

WORK TELEPHONE NUMBER: Please provide your work phone number.

ALTERNATE TELEPHONE NUMBER: Please provide an alternate phone number where you would like to be contacted other than home or work numbers, for example, cell phone number.

PERSONAL E-MAIL ADDRESS: Please provide your personal e-mail address if you prefer be contacted at this e-mail address.

WORK E-MAIL ADDRESS: Please provide your work e-mail address if available.

PREFERRED WAY TO BE CONTACTED: Please indicate your preferred way to be contacted according to your priority, for example, “1. Home Phone, 2. Work e-mail.”

WORK SCHEDULE/REGULAR DAYS OFF: Please indicate your work schedule and regular days off, for example, “8:00AM – 5:00PM, RDO: Sat and Sun.”

GENDER: Please select either “Male” or “Female.” This information is requested only for statistical purposes.

AGE GROUP: Please select either “Under 40” or “40 and Over.” This information is requested only for statistical purposes.

ETHNICITY: Please select the most appropriate ethnicity. This information is requested only for statistical purposes.
II. RELATED COMPLAINT FILING INFORMATION

If you have also filed this discrimination complaint with another agency, or entity such as the Equal Employment Opportunity Commission (EEOC), or the Department of Fair Employment and Housing (DFEH), please check the appropriate box(es) and indicate the date you filed.


III. THIRD PARTY COMPLAINT INFORMATION

If you (as a Complainant) are/were NOT directly subjected to the alleged discrimination and/or are filing this discrimination complaint on behalf of another employee, please ensure that the questions in this section are answered and the information for the individual who is/was subjected to the alleged discrimination is provided to the best of your knowledge. Please see Section I. COMPLAINANT INFORMATION above for the details.
IV. RESPONDENT INFORMATION

Definition of Respondent: A person(s) against whom a complaint was filed. If a Respondent is NOT identifiable, CDCR will be named as a Respondent in the complaint.

Please indicate the total number of Respondent(s) at the top right corner of this section. If there is more than one Respondent associated with the complaint, please complete this page for each additional Respondent and add to the end of the complaint. You may want to make a copy of the blank page before filling it out. Once a Respondent is identified, please provide the Respondent’s information to the best of your knowledge. Please see Section I. COMPLAINANT INFORMATION above for the details.


V. COMPLAINT (ALLEGATION) INFORMATION

Definition of Allegation: An unproved assertion or accusation.

This section consists of two pages for each individual allegation. Please indicate the total number of allegations at the top right corner of this section. If there is more than one allegation included in this complaint, please complete both pages for each individual allegation and add to the end of the complaint. You may want to make a copy of the blank page before filling it out.



a. Description of discrimination (allegation): Please describe an allegation by explaining who, what, where, when, how, and why you believe that you are/were discriminated against. For example, “On October 17, 2007, I was interviewed for a position for Business Manager I at Folsom State Prison. The position was filled by a Caucasian male though I was more qualified than him. I believe that I was discriminated by the interview panel based on my gender (female) and my race (Asian).”

b. Basis of alleged discrimination: Please check one or more of the appropriate box(es) to indicate what protected basis you believe the alleged discrimination is based on. The descriptions of each protected basis are shown on the first page of these instructions.

c. Type of harm/issue caused by alleged discrimination: Please check one or more of the appropriate box(es) that best describes the discriminatory harm/issue based on the selected basis.

d. Respondent(s) associated with this allegation: Please identify the Respondent(s) associated with the allegation by the Respondent # and the Respondent’s name. It is possible that not all the Respondents are responsible for all allegations.

e. What was the date of the last discriminatory action? Please indicate the last (NOT the first) date of the alleged discriminatory action or practice for the allegation.

f. Was the discriminatory action ongoing? Please indicate whether the alleged discriminatory action(s) or practice is/was ongoing (continuous). If it is/was ongoing, indicate the first date that alleged discriminatory action or practice began.

g. Did you or anyone report the allegation to any supervisor…?: Please indicate whether you or anyone reported the allegation to any supervisor or manager, EEO Counselor, EEO Coordinator, hiring authority, or OCR, prior to filing this complaint. If the answer is “Yes,” please provide the name of the person the allegation was reported to, date reported, job title, and action taken, if any action was taken by the person. If you have reported to more than three individuals, please use the space under “ADDITIONAL COMMENTS” on the last page to complete.

h. Evidence: Please indicate whether you have any evidence to support the allegation. If the answer is “Yes,” please describe what kind of evidence it is, such as a letter, a memo, or a photo. If you have more than three pieces of evidence to list, please use the space under “ADDITIONAL COMMENTS” on the last page to complete.

i. Witness: Please indicate whether you have any witness(es) who can provide information related to the allegation. If the answer is “Yes,” please provide the witness’ name, relationship to you, and information the witness can provide. Please note that the first-hand knowledge provided by a witness is more supportive than second-hand knowledge (not personally observed but told about by another person). If you have more than three witnesses, please use the space under “ADDITIONAL COMMENTS” on the last page to complete.
VI. REMEDY REQUESTED

Definition of Remedy: Something that prevents or corrects a wrong or enforces a right.
Please describe the remedy you are requesting if the allegation is supported by the OCR’s investigation. Also indicate if you are willing to participate in mediation.
Remedies may be available for employment discrimination under federal and State laws and the policy of CDCR including, awarding or ordering reinstatement, back pay, out-of-pocket losses, affirmative relief, training, policy changes, and emotional distress damages and administrative fines.




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