Workplace Harassment Complaint Form

REPORTING PERSON INFORMATION

Your Name*
Your Job Title

*You may submit a report anonymously. However, please understand that the School’s ability to investigate and to respond to anonymous information may be limited.

REPORTED INFORMATION

(1) Please describe the conduct or incident(s) that is the basis of this report. Please use additional sheets of paper if necessary and attach any relevant documents or evidence currently available to you:
(2) Please list the date(s) that the incidents occurred (provide approximate dates, if you do not have exact dates):
(3) Please list the name(s) of any witnesses or individuals that may have information related to the incidents of concern:
(4) Have you previously reported this conduct? If so, please explain the person(s) to whom the information was reported and any action(s) taken about which you are aware:
(5) What action would you like the School to take in response to this situation?**:
**The School will consider your preference and additional information gathered through an investigation. The School may not necessarily respond in the way most preferred by the reporting individual. However, a reporting individual’s wishes will be considered when deciding what responsive action is appropriate.

Thank you for reporting this information. We will be in touch with you promptly. If any additional incidents occur, including if you experience any act of retaliation, please inform the Office of Administration & Human Relations immediately.