DBGA EXHIBIT

ANGELINA COLLEGE: EMPLOYEE COMPLAINT AND APPEAL FORM

All formal complaints and appeals must be submitted using this form, and all fields must be completed. If a field is not relevant, write “N/A” in the space provided. Please note Complaints alleging discrimination, including violations of Title IX of the Education Amendments Act of 1972, as amended (sex and gender), Title VII of the Civil Rights Act of 1964, as amended (race, color, religion, national origin), Age Discrimination in Employment Act of 1967, as amended (age), or Section 504 of the Rehabilitation Act, as amended, and the Americans with Disabilities Act of 1990 as amended (disability), shall be submitted in accordance with the Employee Freedom from Discrimination, Harassment, and Retaliation regulation (see: DIA Regulation in the AC Policy and Procedure Manual).

Field 1: Employee Name: _____________________________ Field 2 :Date: ___________________

Field 3: Mailing Address: _________________________________________________________________

Field 4: Email Address: ____________________________ Field 5: Phone Number: __________________

Field 6: Select One Option by Filling in the Corresponding Circle:

		OR	○	DISCRIMINATION/HARASSMENT
○	LEVEL ONE: Complaint to Supervisor		Title IX & Title VII: submit form to Executive Director of Student Affairs ADEA, ADA & Section 504: submit form to Senior Director of Human Resources All other Discrimination: submit form to College President
○	LEVEL TWO: Appeal to Next Level Supervisor
○	LEVEL THREE: Appeal to College President
○	LEVEL FOUR: Appeal to Board of Trustees		○	VIOLATION OF LAW
			Violation of law by supervisor that is not related to Discrimination/Harassment: submit form to College President

You may attach any relevant documents to this form. You may also attach additional pages if the spaces provided below are insufficient. If you choose to attach additional pages, please write “see attached” in the space(s) below.

Field 7: Complaint

Be specific (e.g., full names - including the name(s) of responsible person(s), date the alleged incident occurred, location(s), relevant rule(s) & regulation(s), etc.). The complaint must be in relation to an incident that has already occurred. Do not reference multiple matters or matters already addressed in a complaint you previously submitted.

Field 8: Adverse Effect: Explain how the alleged action or issue adversely affected you.

Field 9: Requested Relief: State the specific corrective action or relief you are requesting. The corrective action or requested relief must be within the authority of AC to grant.

Field 10: Names of Witnesses who have firsthand knowledge of the events being complained:

_________________________________ ____________________________________

__________________________________________________ ______________________________________________________

Field 11: Name of Representative: ____________________________○ No Representative Chosen

“Representative” means any person who or organization that is designated by an individual to represent the individual in the complaint process. The individual may designate a representative through written notice to the College at any level of this process. If the individual designates a representative with fewer than three days’ notice to the College before a scheduled conference or hearing, the College may reschedule the conference or hearing to a later date, if desired, in order to include the College’s counsel.

SIGNATURE

_________________________________________ ____________________

SIGNATURE DATE

__________________________________________

PRINTED NAME

*DGBA Local Policy can be found on Angelina College’s ‘Policies and Procedures’ web page. https://www.angelina.edu/policies-and-procedures/

The Vice President of Business Affairs is responsible for reviewing and updating this regulation. Policy reviews are made in accordance with the Office of Institutional Effectiveness Policy Tracking document.

Document History

Adopted by Board of Trustees: 05/2017

Revised: 08/2023