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
