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