” PCI 11135\/AGENCY Revised 12\/16 Page 1 of 3 CALIFORNIA DEPARTMENT OF FAIR EMPLOYMENT AND HOUSING COMPLAINT FORM FOR STATE AGENCIES Discrimination by State-funded or financially assisted programs This complaint form is to be used by State agencies that administer a program or activity funded directly by the State, or that receives any type of financial assistance from the State, when the agency has reasonable cause to believe that a contractor, grantee, or local agency has discriminated against or denied full and equal access to the benefits of any program or activity on the basis of sex, race, color, religion, ancestry, national origin, ethnic group identification, age, mental disability, physical disability, medical condition, genetic information, marital status, or sexual orientation. Such discrimination includes denial or restriction of access to public accommodations (such as housing or businesses), as well as to streets, highways, hospitals, and other public facilities and places. If the agency has reasonable cause to believe that such discrimination has occurred, it should submit this complaint form along with any supporting evidence and its investigatory file. The completion and submission of this complaint will initiate an intake interview and investigation by the Department of Fair Employment and Housing (DFEH). COMPLAINING AGENCY: NAME OF STATE AGENCY: NAME AND TITLE OF AGENCY CONTACT: TELEPHONE NUMBER: ADDRESS: EMAIL ADDRESS: CITY\/STATE\/ZIP: RECIPIENT OF STATE FUNDING OR FINANCIAL ASSISTANCE (CONTRACTOR, GRANTEE, OR LOCAL AGENCY): NAME: TELEPHONE NUMBER: ADDRESS: ___________________________________________________________________________________________________________________________ CITY\/STATE\/ZIP ________________________________________________________________________________________________________________________ NUMBER OF EMPLOYEES: 1. Our agency has reasonable cause to believe that the above-named recipient of state funding or financial assistance has discriminated against an individual or denied that person full and equal access to the benefits of a program or activity on the basis of one or more of that individual’s actual or perceived characteristics or because of that individual’s association with a person who has or is perceived to have one or more of the following characteristics: Age Ancestry Color Disability – (physical or mental) Ethnic Group Identification Genetic Information – (information about genetic tests or participation in clinical research or manifestation of disease) Marital Status Medical Condition – Including cancer or cancer related medical condition or genetic characteristics (a gene, chromosome or characteristic not presently associated with symptoms of disease) National Origin – Includes language use restriction and use and possession of a driver’s license issued to persons unable to prove their presence in the U. S. is authorized under federal law Race PCI 11135\/AGENCY Revised 12\/16 Page 2 of 3 Religion – Includes religious dress and grooming practices Sex – Gender Sex – Gender identity or Gender Expression Sex – Includes pregnancy, childbirth, breastfeeding and\/or related medical conditions Sexual Orientation Other – (specify) AS A RESULT, THAT INDIVIDUAL WAS DENIED FULL OR EQUAL ACCESS TO THE BENEFITS OF, OR SUBJECT TO DISCRIMINATION UNDER, A PROGRAM OR ACTIVITY FUNDED OR RECEIVING FINANCIAL ASSISTANCE FROM THE STATE OR A STATE AGENCY. DATE OF MOST RECENT HARM (Month\/Day\/Year): IDENTITY OF INDIVIDUAL(S) BELIEVED TO HAVE BEEN SUBECTED TO DISCRIMINATION: NAME: TELEPHONE NUMBER: ADDRESS: CITY\/STATE\/ZIP: NAME: TELEPHONE NUMBER: ADDRESS: CITY\/STATE\/ZIP: NAME: TELEPHONE NUMBER: ADDRESS: CITY\/STATE\/ZIP: *If too numerous to list, or if a group or class of individuals was affected by discrimination, please indicate that, and include a list of individuals or a description of the group or class either below, or as an attachment to the supporting evidence or investigatory file. PCI 11135\/AGENCY Revised 12\/16 Page 3 of 3 2. Briefly describe the program or activity of the contractor, grantee or local agency that is the recipient of state funding or financial assistance, and the discrimination or denial of full and equal access: 1 | P a g e California Department of Fair Employment & Housing Privacy Policy The California Department of Fair Employment & Housing (DFEH) has adopted this Privacy Policy, effective January 1, 2017. DFEH values the security and privacy of your personal information and is committed to protecting your privacy rights. The DFEH seeks only to collect relevant personal information that enables us to assist you in investigating and resolving complaints of discrimination as prescribed by California Government Code sections 11135 et seq., 12900 et seq., and California Civil Code sections 51, 51.7, 52.5, and 54 et seq. All personal information we collect is governed by the State of California Information Practices Act of 1977 (Civ. Code, 1798-1798.78), Government Code sections 11015.5and 11019.9, and the California Public Records Act (Gov. Code 6250 et seq.). Outlined below is our online Privacy Policy and Notice: Legal Authority for Collection and Use of Information Disclosure and Sharing What happens to information you submit to us? Cookies Links Public Disclosure Minors Security Changes to our Privacy Policy Access and Corrections to your Personal Information How to contact us if you have any questions regarding this policy Effective date Legal Authority for Collection and Use of Information We collect information that may be directly associated with a specific person. We call this \”Personal Information,\” and it includes, names, addresses, telephone numbers and email addresses. We collect this Personal Information through lawful means from individuals who seek to file a complaint with the DFEH, and we use this information to establish jurisdiction and to conduct an investigation of any allegations of Civil Rights violations. If you seek to file a complaint, you are required to provide us with sufficient information in accordance with California Government Code sections 11135 et seq., 12900 et seq., and California Civil Code sections 51, 51.7, 52.5,and 54 et seq. Disclosure and Sharing We do not sell your personal information. Government Code section 11015.5, subdivision (6), prohibits DFEH and all state agencies from distributing or selling any electronically collected personal information about users to any third party without the permission of the user. Any distribution of electronically collected personal information will be solely for the purposes for which it was provided to us, as described below. We also may share your personal information under the following circumstances: 1. You give us permission. 2| P a g e 2. We receive a request from a party with legal authority to obtain the information, such as a subpoena. 3. As authorized by law, it is transferred to \/ shared with the U.S. Equal Employment Opportunity Commission, the National Labor Relations Board, the U.S. Department of Labor, the U.S. Department of Housing and Urban Development, the U.S. Department of Health and Human Services, the U.S. Department of Education, the U.S. Department of Justice, or any branch of the California State Government, or any other local or Federal agency with similar jurisdiction. 4. Non personal information, including the allegations in the complaint document itself, may be disclosed to the public under the California Public Records Act. What happens to information you submit to us? The Personal Information we obtain from you will be used for the purposes for which it was provided: to further the DFEH’s efforts to investigate and attempt to resolve the allegations of unlawful discrimination, harassment and\/or retaliation that you filed. Electronically collected Personal Information we gather about visits to our website is used to help us improve the user experience and for basic web metrics of our website. Links Our website may contain links to other websites on the Internet that are owned and operated by third parties. DFEH does not control the privacy policies or practices of these websites. You are advised to review the privacy policies of the third party offering the website before providing any personal information to these websites. DFEH is not responsible for the content or practices of any linked third party website and such third party websites are provided solely for the convenience and information to our visitors. Cookies We do not collect information such as names, addresses, and emails from individuals browsing DFEH’s website. However, when you visit our website, a cookie may be saved on your computer. A cookie is a tiny piece of data stored by your browser that helps us recognize your unique computer and your preferences when using our website. The information DFEH automatically collects may include the type of browser used, date and time you visited the site, and web pages you visited. This information is collected to improve the user experience and for basic web metrics. The information is deleted after 30 days. This type of electronic information collection is permitted by law and is exempt from requests made under the Public Records Act. You can refuse the cookie or delete the cookie file from your computer after you visit our website. You can find instructions for managing cookie controls on websites for particular browsers. For example: Microsoft Internet Explorer browsers Macintosh Safari browsers Mozilla Firefox browsers Public Disclosure In the State of California, laws exist to ensure that government is open and that the public has a right to access appropriate records and information possessed by state government. At the same time, there are exceptions to the public’s right to access public records. These exceptions serve various needs including maintaining the privacy of individuals. Both state and federal laws provide exceptions. All information collected at this site becomes a public record that may be subject to http:\/\/support.microsoft.com\/kb\/278835 http:\/\/www.apple.com\/safari\/features.html#security http:\/\/kb.mozillazine.org\/Cookies 3 | P a g e inspection and copying by the public, unless an exemption in law exists. In the event of a conflict between this Privacy Notice and the Public Records Act, the Information Practices Act and\/or other law governing the disclosure of records, the Public Records Act, the Information Practices Act and\/or other applicable law will control. Minors We recognize the importance of protecting privacy where minors (a person under 18 years of age) are involved. We are committed to protecting the privacy of minors and do not knowingly collect personal information from minors or create profiles of minors through our website. Users are cautioned, however, that the collection of personal information submitted online or in an e-mail will be treated as though it was submitted by an adult. DFEH strongly encourages parents, guardians and adults to be involved in the internet activities of their children or other minors they are responsible for and to provide guidance whenever minors are asked to provide personal information online. If you believe a minor has provided us with personal information, we ask that a parent or guardian contact us at 1-800-884-1684. Security DFEH has put security measures in place to safeguard and protect your information from unauthorized access, disclosure, and loss. Our policy limits access to personal information to employees who have an established business need for the Personal Information including those directly involved in the filing, investigation, resolution and\/or litigation of your complaint. Information that is physically located within the DFEH is protected by various security measures, which may include the use of encryption software to protect the security of an individuals’ personal information during transmission and storage. Personal Information is destroyed according to the DFEH’s records retention policy, and we only retain these records for as long as necessary to fulfill our business need. We train our employees on procedures and management of personal information we collect as well as on taking precautions and complying with limitations on the release of personal information. Access and Corrections to your Personal Information You have the right to review any Personal Information we collect about you. If you request all or a portion of the Personal Information collected about you by the DFEH, we will provide you with the Personal Information requested and explain how we use the information. You may request changes to your Personal Information you believe is incorrect by submitting a written request that credibly shows the error. If you believe that your Personal Information is being used for a purpose other than what you intended when you submitted it, you may contact us to so we can rectify the misuse. In all cases, we will take reasonable steps to verify your identity before granting access or making corrections. How to contact us if you have any questions regarding this policy If you have any questions or concerns about the information presented in this Privacy Notice, you may contact: DFEH Privacy Officer 2218 Kausen Drive, Suite 100 Elk Grove, CA 95758 1-800-884-1684 4| P a g e Changes to our Privacy Policy We may update and revise our Privacy Policy. We will post any privacy policy changes on this page and, if the changes are significant, we will provide a more prominent notice. Effective date January 1, 2017 CALIFORNIA DEPARTMENT OF FAIR EMPLOYMENT AND HOUSING \uf0b7 Legal Authority for Collection and Use of Information Disclosure and Sharing What happens to information you submit to us? Links Cookies Public Disclosure Minors Security Access and Corrections to your Personal Information How to contact us if you have any questions regarding this policy Changes to our Privacy Policy Effective date TELEPHONE NUMBER: ADDRESS: CITYSTATEZIP: NUMBER OF EMPLOYEES: Age: Off Ancestry: Off Color: Off Disability physical or mental: Off Ethnic Group Identification: Off Genetic Information information about genetic tests or participation in clinical research or manifestation of disease: Off Marital Status: Off Medical Condition Including cancer or cancer related medical condition or genetic characteristics a gene chromosome: Off National Origin Includes language use restriction and use and possession of a drivers license issued to persons unable: Off Race: Off Religion Includes religious dress and grooming practices: Off Sex Gender: Off Sex Gender identity or Gender Expression: Off Sex Includes pregnancy childbirth breastfeeding andor related medical conditions: Off Sexual Orientation: Off Other specify: Off DATE OF MOST RECENT HARM MonthDayYear: NAME_2: ADDRESS_2: CITYSTATEZIP_2: NAME_3: ADDRESS_3: CITYSTATEZIP_3: NAME_4: ADDRESS_4: CITYSTATEZIP_4: financial assistance and the discrimination or denial of full and equal access 1: financial assistance and the discrimination or denial of full and equal access 2: financial assistance and the discrimination or denial of full and equal access 3: financial assistance and the discrimination or denial of full and equal access 4: financial assistance and the discrimination or denial of full and equal access 5: financial assistance and the discrimination or denial of full and equal access 6: financial assistance and the discrimination or denial of full and equal access 7: financial assistance and the discrimination or denial of full and equal access 8: financial assistance and the discrimination or denial of full and equal access 9: financial assistance and the discrimination or denial of full and equal access 10: financial assistance and the discrimination or denial of full and equal access 11: financial assistance and the discrimination or denial of full and equal access 12: financial assistance and the discrimination or denial of full and equal access 13: financial assistance and the discrimination or denial of full and equal access 14: financial assistance and the discrimination or denial of full and equal access 15: financial assistance and the discrimination or denial of full and equal access 16: financial assistance and the discrimination or denial of full and equal access 17: financial assistance and the discrimination or denial of full and equal access 18: financial assistance and the discrimination or denial of full and equal access 19: financial assistance and the discrimination or denial of full and equal access 20: financial assistance and the discrimination or denial of full and equal access 21: financial assistance and the discrimination or denial of full and equal access 22: financial assistance and the discrimination or denial of full and equal access 23: financial assistance and the discrimination or denial of full and equal access 24: 1: 2: 3: 4: 5: 6: 7: 8: 9: 10: 11: 12: 13: 14: NAME: zipiti: adeseses: ”
