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:  _______________________________