Name of complainant:_____________________________________________

Date of complaint:_______________________________________________

Name of person alleged to have discriminated or engaged in harassment: ________________________________________

Date and place of incident or incidents:_____________________________________________ ____________________________________________________________________________

Description of misconduct: _____________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________________________________

Name of witnesses (if any): ______________________________________________________ ________________________________________________________________________________________________________________________________________________________

Evidence of harassment, 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:________________________

 

Adopted:  8/18/20