502.10E1 - Harassment Complaint Form

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

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Date

Approved:  11/16/2020                       Reviewed: 10/19/2020            Revised:   10/19/2020