Startup Workplace Harassment Complaint Form

Ensure that all sections of the form are filled out accurately and thoroughly. Use checkboxes to indicate the nature of the harassment and any witnessed incidents. Once completed, submit the form to the designated contact person or department to ensure immediate response.

Personal Information

Full Name:
Employee ID (if applicable):
Department/Team:
Date of Incident:

Incident Details

Nature of Harassment

Please check the appropriate box or boxes that describe the nature of the harassment:

• Verbal Harassment

• Physical Harassment

• Sexual Harassment

• Cyberbullying

• Discrimination

Description of Incident

Date	Time	Location	Description of Incident
January 14, 2055	2:30 PM	Breakroom, 3rd Fl	[Offender Name] used offensive language, making derogatory comments

Witnesses Information

If there were any witnesses to the incident, please provide their names and contact details (if known).

1. Witness 1

Name:	John Miller
Contact Number:	john@email.com

2. Witness 2

Name:
Contact Number:

                                                                                                                                         

Your complaint will be handled with the utmost confidentiality. Please be assured that we will take the necessary steps to investigate and address the matter appropriately. If you have any further questions or concerns regarding this complaint form, please contact [Contact Person/Department] at [Contact Person/Department Email]. Thank you for bringing this matter to our attention.

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