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2. Person(s) Involved

   Please list the person(s) who is directing this harassment towards you.

4. First and Last Name*

   John Doe

6. Department*
7. Telephone*

   XXX-XXX-XXXX

9. Height*

   __Feet __Inches

10. Weight*

    ____Lbs.

11. Age*

    ___ Years

13. Hair Color:*
14. Eye Color:*
15. Gender*
19. Location*

    Where does/did the incident(s) occur?

21. Time*

    When does/did the incident(s) occur?

23. Description*

    How you were harassed; if the harassment included body contact and to what extent; what if any, gestures or language were used; and if there are any witnesses to the incident(s). Indicate if there were any threats or promises in connection with the harassment.

25. Discussions About Harrassment
27. Have you discussed the situation with the person(s) involved in directing their harassment towards you?*

    1. Yes
    2. No
28. If yes, please list date(s), time(s) and location(s) of this discussion and what was the response:
29. If no: why not?
31. Have you discussed this situation with the person's supervisor?*

    1. Yes
    2. No
32. If yes, please list date(s), time(s) and location(s) of this discussion and what was the response:
33. If no: why not?
35. Have you discussed this situation with your supervisor?*

    1. Yes
    2. No
36. If yes, please list date(s), time(s) and location(s) of this discussion and what was the response:
37. If no: why not?
39. Please list any additional information which you feel would be helpful for the 'city' in investigating your complaint:*

    If none, answer "N/A"

41. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) The above summation of my complaint is accurate to the best of my knowledge 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
43. Electronic Signature*
Leave This Blank:


45. 1. Receive an email copy of this form.
46. Email address

    This field is not part of the form submission.

47. Submit

* indicates a required field