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_____________________________________________________
