Harassment Or Discrimination Complaint Form (Page 2 of 2) in pdf

3. Please identify employees who are witnesses to the conduct or incident(s), which form the

basis of your complaint.

__________________________________________________________________________________

4. Please indicate the date(s) and time(s) that the conduct or incident(s) occurred.

__________________________________________________________________________________

5. Where did the incident(s) occur?

__________________________________________________________________________________

6. Have you reported the incident(s) in question to anyone else? If so, please indicate the

date of the report, and the person to whom you made the report.

__________________________________________________________________________________

7. If you have previously reported the incident(s) or conduct, please describe your

understanding of whether any steps were taken to investigate your report, or any

corrective action that was taken.

__________________________________________________________________________________

8. Are you looking for specific corrective action to be taken at this juncture? If so, please

describe what action you are seeking.

__________________________________________________________________________________

Signature___________________________

Date____________________________________

Horry County is an equal opportunity employer. It is Horry County Government’s policy that all

employees have a right to work in an environment free of discrimination and harassment based upon

sex, age, race, color, national origin, religion, disability, or any other class, which is protected by law.

Horry County prohibits retaliation against any employee for complaining about discrimination or

harassment.

Harassment Or Discrimination Complaint Form Page 2