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: _________________________