Harassment Or Discrimination Complaint Form
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2DISCRIMINATION OR HARASSMENT COMPLAINT FORM
The information you provide below is considered sensitive and will be shared only with those who are
considered essential to the investigation and disposition of this complaint. Do not feel limited by the
space provided—you are encouraged to attach additional pages if you believe it will assist in the
investigation.
Your Name__________________________________________
Position_____________________________________________
Department__________________________________________
Phone Number________________________________________
Immediate Supervisor__________________________________
1. Please describe as fully as possible the specific facts of the incident(s) that you are
reporting.
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2. Please provide the name(s) and position(s) of those persons who engaged in the conduct
that is the subject of your complaint.
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