Workplace Bullying & Harassment Complaint Form


Name of Complainant:
Person(s) suspected of harassment (Respondent):

Nature of the allegations

Incident	Date	Time	Place

Did anyone witness the incident? [ ] YES [ ] NO


If YES	Name of witness(es):
Description of their respective role in the incident:
How did you react to the harassment?
If applicable, describe any incident that took place previously:

I hereby certify that to the best of my knowledge the above-mentioned information is true, accurate and complete. Making false or frivolous allegations is in violation of this policy and subject to disciplinary sanctions.

Furthermore, I realize that an inquiry will be initiated once this complaint has been filed.

Signature of the Complainant ____________________ Date ____________________