Workplace Harassment Complaint Form

Workplace Harassment Complaint Form
Name
Job Title
Department/Location
Phone Number
Format: (000) 000-0000.
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)

Other
Witnesses (if any)
Previous Reporting: Have you reported this is incident to anyone else?
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
Date

MonthDayYear
Date
Should be Empty: