Respect or Bullying Policy Violation Complaint Form and Request for Assistance

Please Complete All Fields

This purpose of this form is to ensure employees are provided opportunities to report issues and seek the necessary support needed to confront and address issues of racial bias, bullying, micro-aggressions, and any other forms of disrespectful, unfair, or mistreatment. The use of this form is aligned with DPH's Respect Policy, and should be used to report any perceived violations that could, or may be in violation of our respect policy.

We recognize that we have persisting issues with over-enforcement of Disciplinary and Corrective Actions towards African American and Black employees here at the DPH, as well as Citywide. We also recognize that there historical and ongoing issues with racial bias that influence how Black, Indigenous, Hispanic, Latinx, and other minoritized people and groups experience employment in hiring, promotions, pay, releases, and terminations. Accountability for conduct or the lack thereof can also be, and most times are impacted by where individuals are placed in organizations (i.e. management not held accountable the same as staff, lack of enforcement of discipline and/or corrective action policies, etc.). At the City and County the people occupying management and higher-level positions/classifications are predominantly White and Asian. This impacts all of the employment and workforce areas named above, including accountability for misconduct.

The San Francisco Department of Public Health's Code of Conduct contains both policies on Respectful Behavior (page 14), and Bullying in the Workplace (page 7).

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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 your Disaster Service Worker (DSW) ID number?

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* 4. What is Today's Date

Date / Time

Date

Time

AM/PM

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* 5. Which Division or Unit Do You Work For?

Compliance and Policy Affairs

Human Resources

Security

Information Technology

Finance

Managed Care

MCAH

Jail

Whole Person Integrated Care

Primary Care

Behavioral Health

Population Health - Operations, Finance, Grants

Population Health - Public Health Emergency, Preparedness and Response

Population Health - Center for Learning and Innovation

Population Health - Center for Public Health Research

Population Health - Applied Research, Community Health, Epidemiology, & Surveillance

Population Health - Community Health Equity & Promotion

Population Health - Environmental Health

Population Health - Disease Prevention and Control

Population Health - Emergency Medical Services Agency

Population Health - Bridge HIV

Population Health - Policy

Office of Policy and Planning

Laguna Honda Hospital

Zuckerberg San Francisco General Hospital

Health Information

SF Health Network Quality Management

Enter unit name or division here if not listed above.

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* 6. What is your classification number?

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* 7. What is your job title (please ensure accurate spelling)?

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* 8. Please enter email address here

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* 9. Please enter phone number here

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* 10. What is your race?

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

Hispanic (or referred to as Latina/Latino/Latinx/Latine

Asian (Cambodian, Chinese, Hmong, Japanese, Korean, Laotian, etc.)

Filipino

White

I prefer not to answer

Other (please specify)

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* 11. What is your sex?

Female

Male

Intersex

I prefer not to answer

Other (please specify)

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* 12. What is your gender?

Agender

Bi-Gender

Female/She/Her

Male/He/Him

Transgender

I prefer not to answer

Other (please specify)

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* 13. Please describe your experience regarding your view of how the Respect and/or Bullying policies were violated, 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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* 14. Is your complaint against an individual or multiple individuals? If yes, please write full first name and last names only?

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

Yes

Please clarify below

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* 16. What is/was the date and time of the occurrence?

Date / Time

Date

Time

AM/PM

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* 17. Have you made attempts to resolve your concerns with the individuals named in the complaint? If no, please explain why you have not attempted to speak to your supervisor and/or resolve the issue.

Please Note: It is a very good practice to make attempts to address issues with people directly. Using this approach can often times maintain morale, trust, and provide people with opportunities to become aware of the impacts their behaviors are having on others. It is recommended that an attempt be made to resolve the matter, prior to completing and submitting this form.

Yes

Please clarify below

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* 18. Have you, and/or the parties involved, taken the Respect in the Workplace Training?

Yes

I do not know

Please clarify here:

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

Yes

Please clarify here:

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* 20. Were there any other participants involved? Please list their names below, and also describe their role in the "Other" field

Yes

Please list all others here, and/or describe the roles of people mentioned above.

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

Witness 1:

Witness 2:

Witness 3:

Witness 4:

Witness 5:

Witness 6:

Witness 7:

Witness 8:

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* 22. Do you believe the mistreatment you are experiencing is due to your race/ ethnicity, color, religion or creed, national origin or ancestry, sex (including pregnancy, childbirth, etc.), gender, age sexual orientation, age, physical, mental disability status, veteran status, genetic information, or citizenship?
If the answer to this question is yes, then it is very possible that the situation you are experiencing is an Equal Employment Opportunity (EEO) violation. Please click here to visit EEO and DFEH guidelines to obtain more information about EEO violations. If you believe that your situation fits the violation criteria of a violation, please answer yes to this question.

Yes (If yes, please clarify below)

Other (please specify)

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* 23. Who in the department or unit have you alerted about this situation and other situations, and what were the outcomes? Please include any and all supervisors, mangers, HR, or EEO professionals.

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* 24. Have you and/or are you attempting to seek support from your Labor Union representative? If yes, please share the name of individuals you are working with.

Yes

Prefer not to answer.

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* 25. What type of assistance are you seeking, and what would you like to see happen to resolve your experience and ensure it does not happen in the future?

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* 26. Is this something that you believe can be handled by the SF-DHR Peer Mediation process?

Yes

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* 27. What would you recommend for the person or persons who violated the Respect and/or Bullying policies, to ensure they do not repeat the same conduct or behaviors?