Report Employee Discrimination and Harassment

This form should be used by employees, students, school partners/contractors and others, to report acts of discrimination and harassment where employees are the alleged victim or alleged aggressor.

NOTE: If you are reporting an incident of bullying where a student is the alleged victim, please use the Bullying and Harassment Form.

Employee Discrimination and Harassment Reporting and Investigation Form

General Information
Today's Date - must be mm/dd/yyyy format * Required
Date Format: MM slash DD slash YYYY
Name of person completing this form (First, Last) * Required
First Last
I am (choose one): * Required
I am from this school, OR this office (please provide the full name of your school or the office in which you work): * Required
Email * Required
Best phone number where we can reach you: * Required
Alleged Victim's Name (first, last) * Required
First Last
The alleged victim is:
- Me
- Not me
Alleged Victim is (choose one): * Required
Alleged Victim's School OR Office (please provide the full name of the school or office):
Alleged Victim's Race (choose one): * Required
Alleged Victim's Gender (choose one) * Required
Accused Person's Name (First, Last)
First Last
Accused Person is:
Accused Person's School/Office (please write "Don't know" if you're not sure):
Accused Person's Race:
Accused Person's Gender:
What is the relationship of the alleged victim to the accused person? Is the alleged victim:
- A supervisor of the accused person?
- A colleague of the accused person?
- Someone the the accused person manages?
- I don't know
Describe the Incident
On what Date did the Incident occur? - must be mm/dd/yyyy format * Required
Date Format: MM slash DD slash YYYY
When did the Incident Occur? * Required
Where did the incident occur? * Required
Describe the incident in detail:
Witness Name(s):
Witness Name(s):
Witness Name(s):
Do you believe the incident was based on:
Do you believe the incident was based on:

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Employee Relations

Report Employee Discrimination and Harassment

Employee Discrimination and Harassment Reporting and Investigation Form

General Information

Describe the Incident