Yyyy Details

The College of Saint Rose offers a Pers 497 form to assess and document a student's individual experience in the learning community. The form is designed to be filled out by both the student and professor, and can be used to provide feedback that will help improve the quality of the learning community experience for all students. The College of Saint Rose values your feedback, and we hope you will take the time to fill out this form honestly and thoughtfully.

You may find information regarding the type of form you need to prepare in the table. It will show you how much time it takes to finish pers 497 form, exactly what parts you will need to fill in, and so forth.

QuestionAnswer
Form NamePers 497 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesEEO, YYYY, Texas, TDCJ

Form Preview Example

Texas Department of Criminal Justice

EEO COMPLAINT FORM

Complainant Information (Person Complaining)

Name:

 

 

 

SSN:

 

 

 

Last

First

MI

Title:

 

 

 

Unit/Dept:

 

Work Shift:

 

 

 

Schedule Card:

 

Home Mailing

 

 

Home/Cell

Address:

 

 

Telephone #:

 

 

 

 

Street Address

 

 

 

 

 

(Area Code)

 

 

 

 

 

 

 

 

 

 

 

 

City

State

Zip

Name of Warden/Department Head:

Respondent Information (Person Complained Against)

Name:

 

Title:

 

 

Unit/Dept:

 

 

 

 

 

 

 

 

 

 

 

 

Date(s) of Discriminatory Event:

Earliest:

 

Latest:

 

 

Is the discrimination based on:

 

 

 

 

 

 

 

 

Color?

Race? National origin? Sex?

Sexual Harassment? Age?

Disability?

Retaliation?

Genetic Information? Religion?

Other?

(Check)

 

 

 

 

 

 

 

 

 

 

Yes

No

If yes, identify your color:

 

 

 

 

 

Yes

No

If yes, identify your race:

 

 

 

 

 

Yes

No

If yes, identify your national origin:

 

 

 

 

Yes

No

If yes, identify your sex:

Male

Female

Yes

No

If yes, identify your sex:

Male

Female

Yes

No

If yes, identify your date of birth:

 

 

 

 

 

Yes

No

If yes, identify your disability:

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

If yes, retaliation for having done what?

 

 

 

 

 

 

 

 

 

Yes

No

If yes, specify:

 

 

 

 

 

Yes

No

If yes, identify your religious belief:

 

 

 

 

Yes

No

If yes, specify:

 

 

 

 

Complainant’s Initials: _________

Date:

MM/DD/YYYY

PERS 497 (01/10)

STATEMENT

(Attach additional pages as needed. Number, sign, and date each additional page.)

1. Include specific details such as “who, what, when, and where” for each alleged event of your complaint.

2.List name(s) of all known witnesses and provide, in your own words, a summary of what the witness(es) may testify about the alleged event.

3.List name(s) of all individuals to whom you reported the alleged event and the date(s) you reported the alleged event.

The foregoing statement contains all of my complaint(s), all names of witnesses and all names of individuals to whom I reported the alleged event. This complaint includes this two-page form and ______ additional pages

attached, numbered, signed, and dated. I understand that in addition to any action the TDCJ may take in this matter, I may have filing rights with the Texas Workforce Commission, Civil Rights Division (TWC-CRD) and the U.S. Equal Employment Opportunity Commission (EEOC). I also understand that I may contact the Office of the Inspector General (OIG) if I elect to pursue criminal charges relating to this complaint.

Complainant Signature: ___________________________________

Date: _____________________

 

MM/DD/YYYY

Note to Employee: With few exceptions, you are entitled upon request: (1) to be informed about the information the TDCJ collects about you; and (2) under Texas Government Code §§ 552.021 and 552.023, to receive and review the collected information. Under Texas Government Code § 559.004, you are also entitled to request, in accordance with TDCJ procedures, that incorrect information the TDCJ has collected about you be corrected.

PERS 497 (01/10)

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