Harassment Report Form

Harassment Report Form
REPORT FORM FOR REPORTS OR COMPLAINTS OF SEXUAL HARASSMENT, AND
HARASSMENT BECAUSE OF RACE, NATIONAL ORIGIN, RELIGION AND DISABILITY

Complainant:

Home Address:

Work Address:

Home Phone:

Work Phone:

Date of alleged incident(s):

Did the incidents involve:

sexual
racial
national origin
disability
religion

Name of person(s) you believed harassed you or another person:

If the alleged harassment was toward another person, identify that person:

Describe the incident as clearly as possible, including such things as: what force, if any, was used; any verbal statements (i.e., threats, requests, demands, etc.) what, if any physical contact was involved.

When and where did the incident occur?

List any witnesses who were present:

This complaint is based upon my honest belief that the person(s) named above 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. My First Name is:

Middle Initial:

Last Name:

Today's Date (XX/XX/XXXX):

To validate your submission, please answer the following math problem: