UCLA

UCLA Administrative Policies & Compliance Office
WHISTLEBLOWER RETALIATION COMPLAINT

This form is to be completed to file a “whistleblower retaliation” complaint pursuant to the standards set out in the UC Whistleblower Protection Policy. To determine whether your claim qualifies under this policy, please review UCLA Procedure 620.1: Whistleblower Retaliation Complaints and Attachment B (Standards for Accepting and Evaluating a Whistleblower Retaliation Complaint) and Attachment C (Frequently Asked Questions) of that Procedure. This complaint form appears as Attachment A of UCLA Procedure 620.1.

Submission Deadline and Oath Requirement. Your written complaint must be postmarked by the U.S. Postal Service, personally delivered during University business hours, or received via fax, campus mail, or email within twelve (12) months of when you were formally notified of or otherwise became aware of the Adverse Personnel Action that you allege to be retaliatory. If you allege an ongoing pattern of retaliation, your complaint must be submitted within twelve months of the most recent Adverse Personnel Action. Your complaint must include the Declaration text that appears at the end of the complaint form, or substantially similar words, followed by your signature and the date. If your complaint is accepted, you may then submit to the designated factfinder additional documents and other evidence in support of your complaint.

Delivery Options. You must either submit your complaint to the Locally Designated Official or to your supervisor (who shall promptly forward it to the Locally Designated Official):

 

Mailing/Delivery Address UCLA Administrative Policies & Compliance Office Attn: Locally Designated Official Box 951366, Wilshire Center 700 Los Angeles, CA 90095-1366 Fax Attn: Locally Designated Official (310) 794-8536

Campus Mail UCLA Administrative Policies & Compliance Office Attn: Locally Designated Official Mail Code 136648 Email For an email submission, you must print, sign, and scan the three-page complaint form as a PDF, and email it to compliance@conet.ucla.edu.

Complainant   q Current UCLA employee    q Former UCLA employee    q Applicant for UCLA employment    

Your Name	Department		Phone
Mailing Address		E-mail

You have the option to designate someone to function as your representative during the complaint process. This individual could be an attorney, union representative, or another person who is not involved as a party or potential witness in the proceeding or otherwise conflicted in his or her role. Before naming a representative in your complaint form, you should confirm that any person you may designate as your representative is willing to serve in that capacity. Also, if you intend that further correspondence concerning your complaint should be sent to your designated representative, please check the box below.

Complainant’s Designated Representative (optional)    q Send future correspondence to my representative.

Name	Affiliation/Company (e.g., law firm, union)		Phone
Mailing Address		E-mail

Other Actions. Identify any other grievances/formal complaints you have filed over the same adverse personnel action(s) listed in this complaint form.

Grievance/Complaint Number	Date Filed	Filed with (Department or Entity)

 

Respondent (you must identify at least one person responsible for each Adverse Personnel Action you experienced)

Name/Title of Respondent No. 1

Name/Title of Respondent No. 2

(if more than two individuals, attach additional pages labeled “RESPONDENTS”)
 

Adverse Personnel Action(s) you experienced

As to each action, identify when it occurred and the Respondent(s) responsible for taking the action.

(as needed, attach additional pages labeled “ADVERSE PERSONNEL ACTIONS”)

 

Protected Activity

For each Protected Disclosure, identify what you reported and specify when, to whom, and how (e.g., in person, via e-mail) the report was made.

For each Refusal to Obey an Illegal Order, identify the order you refused to obey and specify who gave the order, when and how it was communicated to you, what law or regulation the order violated, and when and how you refused to obey it.

(as needed, attach additional pages labeled “PROTECTED ACTIVITY”)

Contributing Factor Basis

Identify the facts that you believe demonstrate that your Protected Activity contributed to the Adverse Personnel Action you experienced.

(as needed, attach additional pages labeled “CONTRIBUTING FACTOR BASIS”)

If your whistleblower retaliation complaint is accepted for evaluation, the complaint and any supporting documents you submit may be shared, at the discretion of the factfinder, with the Respondent(s) you claim retaliated against you and with University officials responsible for processing and evaluating the complaint.

Declaration. I swear under penalty of perjury under the laws of the State of California that the facts set forth in my Whistleblower Retaliation Complaint and in any complaint statement submitted herewith are true and correct to the best of my knowledge and belief.
 

 

Complainant Name (printed)

Signature

Date

 

 

Rev. May 2017