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COMPLAINANT FORM
For Harassment and Discrimination Incidents Involving Student Employees or Employees
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Date: ____/____/____
Name of Complainant: _________________________________________________________________
Department: __________________________________________________Phone: _________________
Current Supervisor: _____________________________________________Phone: _________________
Complaint Filed Against: _______________________________________________________________
Department: __________________________________________________Phone: _________________
Nature of Complaint: (Detailed information may be attached to this form.) _____________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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Date and Time of Incident(s): ____/____/____ ____:____ a.m.____ p.m.____
____/____/____ ____:____ a.m.____ p.m.____
Location of Incident(s): _________________________________________________________________
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Witnesses to Incident(s)? ____ No ____ Yes (please identify below)
1. ___________________________________________________________Phone: __________________
2. ___________________________________________________________Phone: __________________
3. ___________________________________________________________Phone: __________________
4. ___________________________________________________________Phone: __________________
Revised 6/06