Sexual Harassment Complaint Form
Information about Complainant
Name
First Name
Last Name
Job Title
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Post Code
Which one(s) do you prefer to be contacted by?
Email
Phone
In person
Other
Information about Supervisor
Name of Supervisor
First Name
Last Name
Title
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Information About Complaint
Name of Complaint
First Name
Last Name
Title
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Work Address
Street Address
Street Address Line 2
City
State / Province
Post Code
Relationship to the complainant
Supervisor
Subordinate
Co-worker
Other
Sexual Harassment Information
Please enter the date(s) the sexual harassment was occurred. If you remember the time(s), you can enter.
Does sexual harassment continue?
Yes
No
Please explain what happened in detail.
Please provide any related files (Photos, documents, voice records, etc.)
Browse Files
Drag and drop files here
Choose a file
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Have you ever complained or provided information verbally and/or in writing about sexual harassment?
Yes
No
Please give more detail
If there are other involved parties and witnesses, Please write here.
Do you have a lawyer and would like us to work with them?
Yes
No
Please give your lawyer's contact information
Date
-
Month
-
Day
Year
Date
Signature
Submit
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