Our company takes employee complaints of sexual harassment and harassment complaints.

So that we may properly investigate your concern, you are requested to fill out this form as completely as possible. Please use additional sheets of paper where needed. After a prompt and thorough investigation into your complaint, you will be notified of the companys intended action. Should you have any questions about the process, please set them forth at the end of this form and well do our best to answer them. Thank you. Employee Name: Date : Title: Managers Name:

Other Complaint: ____ ____ Threats (Physical / Verbal ) Discrimination _______ age _______ race _______ color Other:(specify)_________________________________________________________

Sexual Harassment form

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Please describe in as much detail as possible the nature of your complaint Please include the following: (Please provide the facts and sequential order of things. 1)When did this occur? 2) Who was present (witness)? 3) What occurred?

4) How did the situation make you feel?

5) How has this affected your work environment?

Sexual Harassment form

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2. When did you report the complaint? 3. Who did you report the complaint to? 4. Describe what the company has done thus far in response to your complaint?

I declare that the facts set forth in this complaint form are true and accurate pursuant to the penalty of perjury under the laws of this State.

Employee signature _____________________________________________________ : Date: _______________________________________

Sexual Harassment form

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