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Sexual Harassment Complaint Form
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Complaint Form: Sexual Harassment, Sexual Assault, Dating Violence, Stalking
PLEASE NOTE THAT YOU HAVE THE RIGHT TO ANONYMOUSLY REPORT THIS INCIDENT. ACCORDINGLY, IN COMPLETING THE FORM YOU DO NOT HAVE TO PROVIDE YOUR NAME OR SIGN THE FORM.
Name
First
Last
Status
*
Student
Staff
Faculty
Administrative Unit and Position Title
Address
Phone
Campus Housing
Tierwester Oaks
University Courtyard
University Towers
Urban Academic Village
Individual engaging in alleged harassment
*
Your relationship to the individual engaging in alleged harassment
*
Supervisor
Co - Worker
Professor/Instructor
Advisor
Student
Please describe the specific act(s) alleged
*
Location(s) of alleged incident
*
Date(s) and approximate time(s)
*
Describe the effect the alleged harassment has had on you
*
Are you aware of others who have witnessed this behavior or others who experienced similar behavior by the individual named above? If so, please provide their name(s), indicate if witness or individual with similar experience, their address(s) and their phone number(s).
*
Did you tell anyone about your experience after the alleged incident? If so please provide the name(s) and telephone number(s) of whomever you spoke to.
*
Did you take any action(s) in an attempt to stop the harassment?
*
Have you filed this report with any other agency or an attorney?
*
Yes
No
What is the name of the agency or attorney you filed the report with?
*
Do you have any suggestion for proposed action to address or resolve the harassment ?
Do you have any additional information and comments?
Signature
Date
Copyright 2016
Texas Southern University
