Home Address


Work Address


Home Phone


Work Phone


Dates of alleged incident(s)


Did the incidents involve:
□ sexual harassment
□ harassment because of national origin
□ racial harassment
□ harassment because of disability
□ physical violence

Name of person you believe harassed  or physically assaulted you or another person


If the alleged harassment or violence was directed toward another person, identify that other person


Describe the incident as clearly as possible, including such things as what force, if any, was used, any verbal statements (i.e., threats, requests, demands, etc.), what, if any physical contact was involved.  Attach additional pages as necessary.

When and where did the incident occur?

List any witnesses who were present:

I hereby certify that the information I have provided in this complaint is true, correct and complete to the best of my knowledge.

Complainant’s Signature


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