Workplace Harassment Complaint Form

Workplace Harassment Complaint Form
Name*
Job Title*
Department/Location*
Phone Number*
Email Address*
example@example.com
Person(s) Involved in the Alleged Conduct. Name(s) and Title(s):*
Description of the Incident(s). Please describe the conduct, including dates, locations, and any witnesses. Attach additional pages if needed:*
Protected Characteristic (if applicable)*

RaceColorReligionSex/GenderGender Identity/ ExpressionSexual OrientationNational Orgin/AncestryAgeDisabilityMedical ConditionMarital StatusMilitary/ Veteran StatusNot SureOther
Witnesses (if any)*
Previous Reporting: Have you reported this is incident to anyone else?*

YesNo
If yes, please specify to whom and when:*
Desired Resolution (optional)*
Acknowledgment

I certify that the information provided is true and accurate to the best of my knowledge.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: