Formal Complaint Form
BROADN leadership will not tolerate sexual harassment, harassment or discrimination based on ethnicity, race, gender, or disability, other forms of harassment, sexual assault, or retaliation. All reports will be taken seriously and investigated.
Name
*
First Name
Last Name
University/Department/Title
*
Email address
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Incident Information
Date and time of alleged incident
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Where did the incident occur?
*
Name of accused harasser
*
(University/Department/Title, if known)
If harassment was towards another person, provide their name here:
Describe the incident(s) as clearly as possible. Include a full description of theevents, and verbal statements (i.e., threats, requests, demands, etc.), and what, ifany, physical contact was involved.
*
List any witnesses who were present:
What actions and/or outcomes would you like to see as a result of this report?
Optional
Certification of information
*
This complaint is based upon my honest belief that the reported individual has harassed me or another person. I hereby certify that the information I have provided in this complaint is true, correct, and complete to the best of my knowledge.
Complainant's Signature
*
Today's Date:
*
-
Month
-
Day
Year
Date
Submit Complaint
Submit Complaint
Should be Empty: