502.13A-E1 - Harassment Complaint Form

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 witness (if any):  _________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

Evidence of harassment, i.e., letter, 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_____________________________________________________