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: _______________________________
