Sexual Harassment Complaint Form

Sexual Harassment Complaint Form

[Company Name]

[Company Name]is aware of your complaint, and will begin investigation immediately.  We will also do our best to ensure confidentiality, for yourself, as well as anyone else involved in this situation.  Only those individuals who need to know any information will have access.

Employee Name: ________________________________________________________

Date:_____________________________

Job Title:_______________________________________________________________

SS#:_______________________________

Department:_____________________________________________________________

Supervisor:______________________________________________________________

Name(s) of Accused:______________________________________________________

Job Title(s):_____________________________________________________________

Describe your relationship to Accused:

Name of witnesses (if any):_________________________________________________

Date/Time of incident:_____________________________________________________

Location of incident:______________________________________________________

Describe the incident:

Have there been similar past incidents involving the accused?_______________________________

I _______________________ certify that the information I have given on this report is true.

___________________________________________________

Signature

___________________________

Date