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Summary: UCSD Equal Opportunity/Staff Affirmative Action
Informal Conciliation Intake Form
Name: ______________________________________________ Job Title: _________________________________________
Department: _________________________________________ Daytime Telephone Number: _________________________
1. Please identify your concern(s) related to UCSD's Nondiscrimination in Employment Policy, the UCSD Principles of
Community, or the UC San Diego Health System Core Values:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
2. In chronological order, describe the event(s) that resulted in your concern:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
3. Please provide us with a list of individuals who can verify your statements, including their names, titles, departments, email
addresses, and telephone numbers:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
4. What outcome(s) are you seeking?
_______________________________________________________________________________________________________
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