Harassment Complaint Form
Harassment Complaint Form
This form is designed to assist individuals making a report under Keuka College’s Harassment Prevention Policy. If you believe you are, or have been, subject to conduct in violation of the Policy, or witness or otherwise become aware of such conduct, you are expected to report that information either verbally or in writing. It is the policy of the Keuka College to promptly and thoroughly investigate such reports.
If you wish to make a written report, you may use this form to do so. After completing this form, please submit it to the Associate Vice President for Human Resources either in person, by mail or email. If you are more comfortable reporting verbally or in another manner, you are welcome to do so.
Keuka College prohibits retaliation against any individual who opposes a discrimination practice, makes a good faith report of discrimination or harassment, or who participates in an investigation of such reports. Your cooperation in truthfully completing this form and providing as much accurate information as possible will enable us to investigate and respond to these matters.
YOUR INFORMATION
Name: _________________________
Home Address: __________________ Work Address: _______________________
_______________________________ ________________________
Personal Phone: _________________ Work Phone: ________________________
Job Title: _______________________ Email: ______________________________
Preferred Communication Method: ______________________________
SUPERVISOR’S INFORMATION
Immediate Supervisor’s Name: ____________________ Title: ____________________
Work Phone: ____________________ Work Address: ________________________
INFORMATION CONCERNING SUSPECTED HARASSMENT
- The name of the person(s) involved in your complaint
Name: ______________________ Title: _____________________
Work Address: _________________ Work Phone: _______________________
Other identifying information: ___________________________
Relationship to you: ¨Supervisor ¨Subordinate ¨Co-Worker ¨Other: ___________
- Please describe the conduct or incident(s) that are the basis of this report and your reasons for believing the conduct is harassment. Please use additional sheets of paper if necessary and attach any relevant documents or evidence.
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- Date(s) harassment occurred: ________________________________
Is the harassment continuing? ¨Yes ¨No
- Please list the name and contact information of any witnesses or individuals that may have information related to your complaint. Please use additional sheets of paper if necessary.
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- Have you previously complained or provided information (verbal or written) about harassment at Keuka College? If yes, when and to whom did you complain or provide information?
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Upon receipt of this report, a College representative will contact you. Every effort will be made to assure that confidentiality will be maintained throughout the investigatory process to the extent consistent with the need to investigate your report and to take appropriate corrective action. For additional information, refer to the Harassment Prevention Policy.
The information provided in this report is true and complete and I request that Keuka College investigate this complaint and advise me of the outcome of the investigation.
Signature: _________________________________ Date: ________________