Workplace Bullying & Harassment Form
This form is intend for individuals to report a workplace bullying or harassment incident that they may have been involved or witness to.
Your Name:
*
First Name
Last Name
Today's date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Your Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of alleged incident:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Was the incident directed towards you or someone else?
*
Me
Someone else
Name of person you believe harassed you:
*
Please include first and last name.
Please identify the other person:
Please provide the first and last name of the individual who the incident was directed towards.
Where did the incident occur?
*
Has this happened before?
*
Please Select
Yes
No
How often did it occur and when:
*
Describe the incident as clearly as possible. Include a complete description of the events, verbal statements, and any physical contact:
It is important to try to recollect the details to the best of your ability.
How did you or the person harassed (if not you) react to the harassment?
*
List any witnesses who were present:
*
If none, please type N/A
Please submit any files related to the incident.
Browse Files
Drag and drop files here
Choose a file
This may include but is not limited to copies of emails, forms, written statements etc
Cancel
of
I hereby certify that the information I have provided in this report is true and correct to the best of my knowledge.
*
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Submit
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