Name of complainant: __________________________________________________________
Position of complainant: ________________________________________________________
Date of complaint: _____________________________________________________________
Name of alleged harasser
or bully: _____________________________________________________________________
Date and place of incident or incidents: _____________________________________________
_____________________________________________________________________________
Description of misconduct: _______________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Name of witnesses (if any): ______________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Evidence of harassment or bullying, i.e. letters, photos, etc. (attached 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: ____________________________