Information
"Company" takes all reasonable steps to ensure that an employee's right to freedom from harassment and discrimination is upheld.
The purpose of this report is to initiate a fact-finding exercise concerning and incident or incidents of workplace harassment. A formal, confidential investigation may be initiated by the appropriate authourity upon receipt of the completed and signed report.
This form is not to be used to report incidents of workplace violence. For violence-related cases, refer to the Policy.
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Name of Complainant:
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Date of Incident(s):
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Name of Respondent(s):
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Work Location:
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Relationship to you:
- Co-worker
- Employee
- Supervisor
- Visitor
- Student
- Client
- Volunteer
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Name of witnesses and/or those involved.
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Provide a thorough description of who, what, where and when, including witness names and dates and times of incident(s).
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Provide a description of the events.
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Have you notified anyone else of the events? It so, who and when?
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What impact has this event had on you?
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Recommendation (if any) / Remedy sought:
"Company" takes every complaint of harassment in the workplace very seriously. You can assist in the investigation of the incident(s) by providing as much information and as many details as possible.
The information contained within this report will be distributed to the parties directly involved in the investigation of the complaint.
By signing this report, you certify that the information herein is factual and accurate to the best of your knowledge.
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Reported by:
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Date:
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Report received by: Date received:
