403.5E1 - 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, Le., 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:

 

 

Approved: February 1996.
Reviewed:  April 2009, January 2011, January 2014, January 2017, May 2020