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.

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

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