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This form is intended to assist Black employees, and allies of Black employees, at the City and County of San Francisco with documenting new and ongoing racially biased issues they are experiencing within their departments, anti-Black racism, as well as official racial discrimination and/or harassment complaints.  It is also intended to assist Black employees with easily documenting their experiences to ensure there are consistent and contemporaneous records of racial abuse and mistreatment.

Discrimination is the unfair or prejudicial treatment of people and groups based on characteristics such as race, gender, age or sexual orientation. 


Harassment is the act of systematic and/or continued unwanted and annoying actions of one party or a group, including threats and demands.  Examples of harassment in the workplace include derogatory jokes, racial slurs, personal insults, and expressions of disgust or intolerance toward a particular race. Abuse may range from mocking a worker's accent to psychologically intimidating employees by making threats or displaying discriminatory symbols.

PLEASE DO NOT FILE COMPLAINTS USING THE CITY AND COUNTY OF SAN FRANCISCO'S DHR-EEO PROCESS.  THE PROCESS IS CORRUPT AND WE ARE GUIDING ALL BLACK EMPLOYEES TO FILE COMPLAINTS THROUGH THE EQUAL EMPLOYMENT OPPORTUNITY COMMISSION AND DEPARTMENT OF FAIR EMPLOYMENT AND HOUSING.
Each journal entry submitted through this process will be emailed back to you for your own records to ensure you are prepared to submit any formal complaints that may be submitted to the EEOC and DFEH.

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* 1. What is your first name?

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* 2. What is your last name?

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* 3. What is Today's Date

Date
Time

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* 4. Which Department Do You Work For?

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* 5. Please enter email address here

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* 6. What is your sex?

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* 7. Do you have a disability; and do you believe the mistreatment, discriminatory, and/or harassment you have experienced is the result of your disability?

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* 8. What is your race?

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* 9. Do you feel like your age (i.e. over 40) played a part in the discrimination or harassment you experienced?

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* 10. Please enter phone number here

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* 11. What is your classification?

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* 12. Is this the first occurrence?  If not, please describe details below.

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* 13. Who is your complaint against (please write full first name and last name only)?

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* 14. Are there any other offenders/perpetrators/harassers?  If so, please list all first and last names?

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* 15. Are any of these people your supervisor or manager; not your direct supervisor or manager but in a role of authority?

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* 16. Do you feel like your gender (i.e. transgender, woman, non-binary, agender, etc.) played a part in the discrimination or harassment you experienced?

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* 17. Do you feel like your sex (i.e. male, female, intersex, etc.) played a part in the discrimination or harassment you experienced?

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* 18. Please describe your experience including  the following: 1.) Who was involved?  2.) What was said or done (please be specific about comments, actions, and their overall impacts).

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* 19. If there were any witnesses (or anyone in the environment), please write in their names here?

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* 20. Who in your department have you alerted about this situation and other situations?

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* 21. Have you filed a Complaint with the City and County Department of Human Resources?  If so, when?  Who did you file the complaint with at DHR (EEO Representatives name)?

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* 22. Have you filed a Complaint with the Department of Fair Employment and Housing (DFEH) or the Equal Employment Opportunity Commission (EEOC), or ACLU?

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* 23. What was the outcome of the complaint filed with DFEH/EEOC (i.e. Right to Sue Letter issuance, lawsuit, etc.)?

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