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: ___________________________________________
