Black Employees Alliance and Coalition Against Anti-Blackness Discrimination and Harassment Journal, & Complaint Form - For Black Employees and Allies of Black Employees

Please Complete All Fields

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? (Required.)

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2. What is your last name? (Required.)

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3. What is Today's Date (Required.)

Date / Time

Date

Time

AM/PM

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4. Which Department Do You Work For? (Required.)

311

Academy of Sciences

Adult Probation

Airport Commission

Animal Care and Control

Arts Commission

Child Support Services

Behavioral Health Services

Child support Services

Children and Families Commission

Children Youth and Their Families

City Attorney

City Administrator/GSA

Controller's Office

County Clerk

Controller's Office

Department of Building Inspection

Department of Elections

Department of Disability and Aging Services

Department of Emergency Management

Department of Police Accountability

Department of Public Health

Department of Technology

District Attorney

Disease and Prevention Control

Department of Environment

Environmental Health

Ethics Commission

Film Commission

Fine Arts Museum

Fire Department

General Services Agency

Homelessness and Supportive Housing

Human Resources

Human Rights Commission

Human Services Agency

Juvenile Probation

Maternal, Child, and Adolescent Health

Mayor's Office of Housing and Community Development

Mayor's Office on Disability

Municipal Transportation Agency

Office of Economic and Workforce Development

Office of Financial Empowerment

Police Department

Port

Public Defender

Public Utilities Commission

Public Works

Recreation and Parks

Rent Board

School District

Library

Planning

Airport

Health Service System

Sheriff's Office

Superior Court

Treasury & Tax Collector

Enter department name here if not listed above.

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5. Please enter email address here (Required.)

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6. What is your sex? (Required.)

Female

Male

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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? (Required.)

Yes (If yes, please clarify below)

Other (please specify)

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8. What is your race? (Required.)

Black (African-American, Afro-Latina, Afro-Asian, etc.)

Hispanic/Latinx

Asian (Chinese, Japanese, Korean, etc.)

Filipino

Other

Other (please specify)

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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?

Yes

Please explain here:

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10. Please enter phone number here (Required.)

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11. What is your classification? (Required.)

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12. Is this the first occurrence? If not, please describe details below. (Required.)

Yes

Please clarify 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?

Person of Interest 1

Person of Interest 2

Person of Interest 3

Please list all others here

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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?

Yes

Please clarify here:

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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?

Yes

Please explain here:

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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?

Yes

Please explain here:

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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). (Required.)

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

Witness 1:

Witness 2:

Witness 3:

Witness 4:

Witness 5:

Witness 6:

Witness 7:

Witness 8:

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

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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)?

Yes

If yes, please write-in EEO Representatives name and date here:

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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?

Black Employees Alliance and Coalition Against Anti-Blackness Discrimination and Harassment Journal, & Complaint Form - For Black Employees and Allies of Black Employees

Please Complete All Fields

Question Title

* 1. What is your first name? (Required.)

Question Title

* 2. What is your last name? (Required.)

Question Title

* 3. What is Today's Date (Required.)

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* 4. Which Department Do You Work For? (Required.)

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* 5. Please enter email address here (Required.)

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* 6. What is your sex? (Required.)

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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? (Required.)

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* 8. What is your race? (Required.)

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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 (Required.)

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* 11. What is your classification? (Required.)

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

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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?

Question Title

* 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). (Required.)

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

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

Question Title

* 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.)?

1. What is your first name? (Required.)

2. What is your last name? (Required.)

3. What is Today's Date (Required.)

4. Which Department Do You Work For? (Required.)

5. Please enter email address here (Required.)

6. What is your sex? (Required.)

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? (Required.)

8. What is your race? (Required.)

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

10. Please enter phone number here (Required.)

11. What is your classification? (Required.)

12. Is this the first occurrence? If not, please describe details below. (Required.)

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

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

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

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?

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

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). (Required.)

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

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

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)?

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

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