Editing previous response:

Please fix the highlighted areas below before submitting.

Sexual Harassment/Discrimination Form

Please complete the form below. Required fields marked with an asterisk *

Name *

Answer required for "Name "

Job Title*

Answer required for "Job Title"

Work Address

Answer required for "Work Address"

Work Phone*

Answer required for "Work Phone"

Email*

Answer required for "Email"

Your complaint of Sexual Harassment is made about:*

Answer required for "Your complaint of Sexual Harassment is made about:"

Please describe what happened and how it is affecting you and your work. Please send any relevant documents or evidence to [email protected]*

Answer required for "Please describe what happened and how it is affecting you and your work. Please send any relevant documents or evidence to [email protected]"

Date(s) sexual harassment occurred:*

Answer required for "Date(s) sexual harassment occurred:"

Please list the name and contact information of any witnesses or individuals who may have information related to your complaint:

Answer required for "Please list the name and contact information of any witnesses or individuals who may have information related to your complaint:"

Optional: Have you previously complained or provided information verbal or written about related incidents? If yes, when and to whom did you complain or provide information?

Answer required for "Optional: Have you previously complained or provided information verbal or written about related incidents? If yes, when and to whom did you complain or provide information?"

If you have retained legal counsel and would like us to work with them, please provide their contact information

Answer required for "If you have retained legal counsel and would like us to work with them, please provide their contact information"

Confirmation Email

Answer required for "Confirmation Email"