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: _________________________
