Name of complainant: ______________________________________________________________________
Position of complainant:_____________________________________________________________________
Date of complaint:__________________________________________________________________________
Name of alleged harasser or bully:_____________________________________________________________
Date and place of incident or incidents:_________________________________________________________
________________________________________________________________________________________
Description of incident or incidents:____________________________________________________________
________________________________________________________________________________________
_________________________________________________________________________________________
Name of witnesses (if any):___________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Evidence of harassment or bullying, i.e., letters, photos, etc. (attach evidence if possible):
_________________________________________________________________________________________
_________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Any other information:________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
I agree that all of the information on this form is accurate and true to the best of my knowledge.
Signature:______________________________________________________
Date: _____ /_____ /_____