Code No. 403.7El
HARASSMENT COMPLAINT FORM
Name of complainant: ________________________________________________________
Position of complainant: ____________________________________________________
Date of complaint: __________________________________________________________
Name of alleged harasser: ___________________________________________________
Date and place of incident or incidents:_____________________________________
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:________________________________________________________________________