1. Person(s) Involved:

Please list the person who is directing the harassment towards you.

Name
Department
Telephone
Office/Room
Height
Weight
Color of Eyes
Color of Hair
Age
Ethnicity
Gender

Are there Others involved in this harassment towards you?
Yes No
(if yes, please fill out a form for each additional person)

What position does this person hold on campus?

2. Location

Where does/did the incident(s) occur?

3. Time

When did the incident(s) occur? (Times and dates)

4. Description:
Please describe the incident(s) and include such information as how you were harasses; if the harassment included body contact and to what extent; what if any, gestures or language were used; and if there were any witnesses to the incident(s). Indicate if there were any threats or promises in connection with the harassment.

5. Have you discussed this situation with the person involved? Yes No
If no, why not? If yes, what was the response? Please list date, time and location of this discussion.

6. Have you discussed this situation with the person's supervisor? Yes No
If no, why not? If yes, what was the person response? Please list date, time and location of this discussion.

7. Have you discussed this situation with your supervisor or the appropriate University administrator? Yes No
If no, why not? If yes, what was the persons response? Please list date, time and location of this discussion.

8. Please list any additional information which you feel would be helpful to the University in investigating your complaint.

The above summation of my complaint is accurate to the best of my knowledge.

Name of person making complaint
Address/Work Location
Telephone Day Evening
Date