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:
Approved 4/11/05
Reviewed 11/15/21
Revised
