Sexual Harassment Reporting Form

Namerequired

First Name

Last Name

Email Addressrequired

Phone Numberrequired

Date/Time of Incidentrequired

Location of Incidentrequired

Select the statement(s) that best describe the incident. Choose all that apply.required

Physical bullying/harassment (e.g. hitting, kicking, punching, spitting, pushing, taking personal belongings)

Verbal bullying/harassment (e.g. taunting, malicious teasing, name-calling, making threats)

Social, emotional, psychological (e.g. non-verbal actions, spreading rumors, manipulating social relationships, engaging in social exclusion, extortion or intimidation)

Electronic communications

Sexual harassment

Workplace violence

Other

If you answered "other" above, please specify.

Please describe what happened before, during and after the incident.required

Names of witnesses, if any:

How have you been injured or harmed by the matter, incident or individual at issue?

What steps, if any, have been tried to resolve this matter?required

Have you previously complained regarding the matter, incident or individual at issue or regarding similar concerns? If so, please detail to whom and provide as much detail as possible.

Have you been absent from school/work as a result of this incident?required

Yes

No

If yes, how many days were you absent?

Certificationrequired

I certify that the above information is accurate to the best of my knowledge.

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