WORKPLACE DISCRIMINATION & HARASSMENT REPORT

EMPLOYEE FIRST NAME

EMPLOYEE LAST NAME

MOBILE PHONE

TODAY'S DATE

DATE OF INCIDENT(S)

LOCATION OF INCIDENT(S)

TOTAL # OF INCIDENT(S)

THE ACCUSED: FULL NAME

THE ACCUSED: PHONE

THE ACCUSED: EMAIL (optional)

THE ACCUSED: DIRECT MANAGER FULL NAME

NAME(S) OF THOSE WHO PARTICIPATED IN THE HARASSMENT / DISCRIMINATORY BEHAVIOR

DETAILS / EVIDENCE OF THE INCIDENT(S)

FULL NAME(S) OF WITNESS(ES)

WITNESS(ES) JOB TITLE & CONTACT INFORMATION

IN THE EVENT A REPORT IS FILED WITH THE EEOC OR DFEH, WOULD YOUR WITNESS(ES) LIKE TO PARTICIPATE IN THE INVESTIGATION? PLEASE LIST THOSE WHO DO.

WHAT IS YOUR DESIRED OUTCOME FROM THE INTERNAL INVESTIGATION?

TYPES OF DISTRESS AS A RESULT OF THE INCIDENT(S)

MULTISELECT

MENTAL

EMOTIONAL

PHYSICAL

WOULD YOU LIKE TO PROCEED WITH EEOC & DFEH?

THE INFORMATION PROVIDED IN THIS REPORT 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 DEEMS RELEVANT AND NECESSARY.