Harassment Report Form
REPORT FORM FOR REPORTS OR COMPLAINTS OF SEXUAL HARASSMENT, AND
HARASSMENT BECAUSE OF RACE, NATIONAL ORIGIN, RELIGION AND DISABILITY
Date of alleged incident(s):
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:
Today's Date (XX/XX/XXXX):