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:
