403.5E1 – Discriminatory Harrassment Complaint Form
| Name of complainant |
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| Position of complainant |
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| Date of complaint |
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| Name of alleged harasser |
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| Date and place of incident or incidents |
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| Description of misconduct |
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| Name of witnesses (if any) |
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| Evidence of harassment, i.e., letters, photos, etc. (attach evidence if possible) |
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| Any other information |
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I agree that all of the information on this form is accurate and true to the best of my knowledge.
| Signature |
__________________________________________ |
Date |
________________________________ |
