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 witness (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: _____________________