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:______________________________

_____________________________________________________________

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: