Employee Name

Branch

Department

Job Title

Individual who allegedly committed harassment

Describe the nature of the Complaint (include dates and as much details as possible)

Identify names of all other employees with knowledge of the incident about which complaining

Did other employees’ names above observe or overhear the alleged incident(s)
Observer
Over Hear
Other

If other

Are there any documentary evidence?
Yes
No

If Yes, attach file:

Have you missed any work time as a result of the alleged harassment?
Yes
No

If yes, provide details:

Have you received any counselling or received medical treatment as a result of this alleged harassment? If yes, indicate dates of counselling / treatment
Yes
No

If yes, indicate dates:

Have you previously complained about this or related acts of sexual harassment? If so, please identify the individual to whom you complained, the date of the complaint and the resolution of your complaint
Yes
No

If yes, provide details:

What is your requested remedy in this complaint?

To investigate your complaint, it will be necessary to interview you, the alleged harasser(s), and any witnesses with knowledge of the allegations or defences. The committee will notify all persons involved in the investigation that it is confidential and that unauthorized disclosures of information concerning the investigation could result in disciplinary action, up to and including termination of employment.

The information provided in this complaint is true and correct to the best of my knowledge. I am willing to cooperate fully in the investigation of my complaint and provide whatever evidence the committee deems relevant.