Notice Of Harassment / Discrimination Complaint Form Page 2

Page Two

Harassment/Discrimination

Complaint Form

Did employees/students/or others listed on the previous page

personally observe or overhear the alleged conduct? If yes, please

indicate the dates of observed/overheard behavior.

Are there documents or emails which contain information supporting

the occurrences described above?

Is there any physical evidence that supports your complaint? If so,

please describe or attach a copy.

Have you missed any work time/class time as a result of the alleged

harassment/discrimination? If yes, please indicate dates of

absences.

Have you received any counseling or received medical treatment as

a result of this alleged harassment? If yes, indicate dates of

counseling/treatment.

Page Three

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Parent category: Legal