Workplace Harassment Complaint Form

Workplace Harassment Complaint Form
Name of complainant:
First NameLast Name
Date you filled out the form:
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone number of the complainant:
Please enter a valid phone number.Format: (000) 000-0000.
Date and time of alleged incident:
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour Minutes
Name of person you believe harassed you:
Where did the incident occur?
Has this happened before?
If yes, how often did it occur:
If the alleged harassment was toward another person, identify that other person:
Describe the incident as clearly as possible. Include a complete description of the events, verbal statements, and any physical contact:
How did you or the person harassed (if not you) react to the harassment?
List any witnesses who were present:
I hereby certify that the information I have provided in this complaint is true, correct, and complete to the best of my knowledge.
Signature of Complainant:
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