Workplace Harassment Complaint Form - Fairfax County Public Schools
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1Workplace Harassment Complaint Form
Use this form to report concern of workplace harassment not based on protected categories (race, color,
sex, pregnancy, marital status, religion, national origin, age, disability, or genetic information). Please
complete every appropriate item and submit it as soon as possible after the incident of alleged
harassment to:
Fairfax County Public Schools
Department of Human Resources
Office of Equity and Employee Relations (EER)
8115 Gatehouse Road, Suite 2500
Falls Church, VA 22042
Phone: (571) 423-3070 Fax: (571) 423-3057
Anonymous complaints will not be accepted.
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Name:
Title:
:_______________________________________________________________
Home Address
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City:
State:
Zip:
: _________________
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Phone #: Home
Cell:
Work:
: _______________
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Employee ID #
School/Work Location:
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E-mail Address:
_________________________
_________________
Supervisor’s Name:
Supervisor’s Phone:
1. Name/Title/Location of person(s) you believe is harassing you.
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Name:
Title:
Location:
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Name:
Title:
Location:
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Name:
Title:
Location:
2. Date(s) on which alleged harassment occurred: _________________________________
3. Where did the harassment occur?_____________________________________________
4. Describe the harassment.
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Parent category: Letters