403.5E1 - Harassment Complaint Form

Name of complainant:  ____________________________________________________

Position of complainant:  __________________________________________________

Date of complaint:  _______________________________________________________

Name of alleged harasser:  _________________________________________________

Date and place of incident or incidents:  _______________________________________
________________________________________________________________________

Date and place of incident or incidents:  _______________________________________
________________________________________________________________________
________________________________________________________________________

Name of witnesses (if any):  _________________________________________________
________________________________________________________________________
________________________________________________________________________

Evidence of harassment, i.e., letters, photos, etc. (attach evidence if possible):  _________
________________________________________________________________________

Any other information:  _____________________________________________________
________________________________________________________________________
________________________________________________________________________

I agree that all of the information on this form is accurate and true to the best of my knowledge.

 

Signature:  _______________________________________

Date:  ___________________________________________