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Workplace Harassment Complaint Form

This form is to be used to document any claim of illegal harassment, including sexual harassment, which occurs in the workplace. To ensure that all harassment complaints are managed appropriately, effectively, and in accordance with the organization’s policy, harassment complaints, including sexual harassment complaints, will be recorded using this form.

Time to complete

3 minutes

Eligibility

An individual who believes that they have been the victim of workplace harassment may file a complaint with their employer.

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Questions for Workplace Harassment Complaint Form

1.

Your complaint of Sexual Harassment is made about

The answer should be a single choice:
  1. Supervisor
  2. Subordinate
  3. Co-Worker
2.

Name(s) of individual engaged in the harassment:

The answer should be a text input.
3.

Please describe the specific incident of harassment alleged. Describe each incident separately,including dates, times and locations. If you cannot remember exact dates, times or locations,please provide approximations. 

The answer should be a text input.
4.

Are there others who may have witnessed this alleged harassment? If so, please provide their name(s). 

The answer should be a text input.
5.

Are there others who may have experienced similar alleged harassment by the individual named above? If so,please provide their name(s). 

The answer should be a text input.
6.

Did you tell anyone about your experience after the alleged incident(s)? If yes, please provide their name(s).

The answer should be a text input.
7.

Are there others who have witnessed this behavior or others who experienced similar behavior by the individualnamed above? If so, please provide their name(s) and state whether they are a witness to this behavior or anindividual who has experienced similar behavior: 

The answer should be a text input.
8.

Did you speak to the individual named in this report about the alleged harassment? If yes, what was his or herresponse? 

The answer should be a text input.
9.

Is the sexual harassment continuing?

The answer should be a single choice:
  1. Yes
  2. No

Similar Ideas

  • Sexual Harassment Complaint Form
  • Physical Harassment Complaint Form
  • Emotional Harassment Complaint Form
  • Retaliation Complaint Form

Here are some FAQs and additional information
on Workplace Harassment Complaint Form

What is harassment?

Harassment is a type of discrimination that is based on a protected characteristic, such as race, religion, gender, or national origin.

What are the different types of workplace harassment?

There are three primary types of workplace harassment: verbal, physical, and visual. Each type of harassment can take on several different forms. Verbal harassment includes any type of offensive or derogatory remarks made to an employee. This can include name-calling, threats, and insults. Physical harassment occurs when an employee is physically assaulted or threatened with violence. This can include hitting, kicking, or pushing. Visual harassment is any type of offensive or derogatory visual material that is displayed in the workplace. This can include offensive graffiti, posters, or cartoons.

What are the consequences of workplace harassment?

Workplace harassment can have a number of negative consequences for both the victim and the company. Victims of workplace harassment may experience a decline in job performance, increased absenteeism, and increased stress levels. They may also suffer from anxiety, depression, and other mental health problems.

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