HTML Preview Harassment Complaint Form page number 1.
HARASSMENT COMPLAINT FORM
(Employee)
Complainant:
Home Address: Home Phone:
Work Address: ______________________________ Work Phone: _________________
Date(s) and time(s) of alleged incident(s):
Name of person you believe harassed you or another person:
If the alleged harassment was toward another person, identify that other person:
Describe the incident(s) as clearly as possible. Include a full description of the events, and
verbal statements (i.e., threats, requests, demands, etc.), and what, if any, physical contact was
involved. Attach additional pages as necessary. _____________
Where did the incident occur? _ _____
List any witnesses who were present: _ ______
How did you or the person harassed (if not you) react to the harassment?
______________________________________________________________________________
______________________________________________________________________________
This complaint is based upon my honest belief that _______
has harassed me or another person. I hereby certify that the information I have provided in
this complaint is true, correct and complete to the best of my knowledge.
_________________________ ___________________________
(Complainant s signature) (Date)
_________________________ ___________________________
(Received by) (Date)