HARASSMENT COMPLAMENT FORM

[Your Company Name]

Full Name:	[Your Name]
Job Title:
Department:
Employee ID:
Date of Complaint:

Complaint Details

1. Nature of Complaint

Sexual Harassment	Discrimination
Bullying	Verbal Harassment
Written Harassment	Other (Specify):

2. Description of Incident(s)

3. Witnesses

Were there any witnesses to the incident(s) or behavior(s)? If yes, please provide their names and contact information if available.

• Yes

• No

Witness Name: [Name]

Contact Information: [Contact Information]

Witness Name: [Name]

Contact Information: [Contact Information]

4. Description of Incident(s)

5. Previous Complaints

Have you previously reported this incident or similar incidents to anyone within the company? If yes, please provide details, including dates and names of individuals involved.

• Yes

• No

Details:

                                                                                                                                                                                                                                                                                                                                                                                                                           

6. Desired Resolution

What is your preferred outcome or resolution for this complaint?

Counseling	Formal Investigation
Training	Other (Specify):
Mediation	Other (Specify):

7. Supporting Documentation

By signing below, you confirm that the information provided in this complaint is true and accurate to the best of your knowledge.

[Signature]

[Employee Name]

Employee

Confidentiality Statement:

This complaint and any related investigations will be handled with the utmost confidentiality to the extent permitted by law. The information provided will only be shared with those individuals directly involved in the resolution process.

[Your Signature]

[Your Name]

HR Representative

This form is for internal use only and should not be disclosed to anyone except those involved in the complaint resolution process or as required by law.

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