Name of complainant: _________________________________________________________________
Position of complainant: _______________________________________________________________
Date of complaint: ____________________________________________________________________
Name of alleged harasser: ______________________________________________________________
Date and place of incident or incidents: ____________________________________________________
____________________________________________________________________________________
Description of misconduct: ______________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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: ________________________________
