Code: ACA-E-1 SEXUAL DISCRIMINATION/HARASSMENT COMPLAINT FORM 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 |