Code No. 404.9E1 Harassment Complaint Form

Harassment Complaint Form

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 witnesses (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:  

 

 

Revised/Reviewed:  January 24, 2022