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Sexual Harassment Complaint Form

Sexual harassment is a serious crime that needs special attention therefore every organization offer special forms for its documentation. It is a sexual crime that involves complaint against an individual. It should be filled up carefully because it helps you to lawsuit against involved persons. Below is a sample sexual harassment form and it will definitely help you to design your own form. It is easy to edit so you can also use it as it is.

Sexual Harassment Complaint Form

Notice:  Complaints filed for acts that occurred more than one year from the filing date of the complaint will generally not be investigated unless appropriate in the judgment of the OAS. 


1.    Name of Complainant:


2.    Status:    Student (   )    USPS  (   )   A&P  (   )    Faculty  (   )   OPS  (   )


Other (specify):

3.    Administrative Unit and Position Title (if employee):


4.    Campus Address:

  Campus Phone Number:


5.    Name of individual engaging in alleged harassment: 



6.    Administrative Unit and Position title of individual named in 5. (if 




7.    Complainant’s relationship to individual engaging in alleged 

  harassment:   Supervisor  (   )    Co-Worker (   )   Professor/Instructor  (   )

  Advisor  (   )    Student  (   )   Other (specify):



8.    Please describe the specific act(s) alleged. 








9.    Location(s) of alleged incident: 


10.  Date(s) and approximate time(s): 


11.  Describe the effect the alleged harassment had on you: 




12.  Are there others who have witnessed this behavior or others who experienced similar behavior by the individual named above?  If so, please provide their names(s), indicate if witness or individual with similar experience, their address(es) and their phone number(s). 








13.  Did you tell anyone about your experience after the alleged incident?  If so, please provide name(s) and phone number(s). 




14.  Actions taken, if any, by the complainant to attempt to stop the harassment. 




15.   Have you filed this report with any other agency or an attorney?   

         Yes  (   )    No  (   )

         If yes, with whom? 



16.  Complainant’s suggestion of proposed action to address or resolve the harassment. 




17.  Additional information and comments: 






Signature of person making the report: 





Signature of person receiving the report: 





Record Number SH



HR Office Use Only

Employment Discrimination Under:

__Title VII of the Civil Rights Act of 1964

__The Age Discrimination in Employment Act of 1967 (ADEA)

Basis of Discrimination:  __Sex (Gender) __Race __Color __Retaliation __Age __Religion

__Creed __National Origin __Disability __Sexual Orientation

__Marital or Veteran Status or any other legally protected classification.

Circumstances of Alleged Violation:

Date: __/__/__


Printed Name of Authorized University Official


Signature of Authorized University Official


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