Sexual Harassment & Retaliation Complaint Form

Sexual Harassment and Retaliation Complaint Form

Complainant Name: 

School Name or Position (if applicable): 

Student Parent Employee Non-employee Job Applicant Other 

Address:  City:  State:  Zip: 


Email Address: 

Date(s) of alleged incident(s)/conduct: 

Location(s) where alleged incident(s)/conduct took place: 

Name of person(s) who engaged in the conduct: 

Names of any witnesses: 

Do you have any evidence (e.g. emails, photos, text messages, etc.)? Yes No

Describe the incident(s)/conduct as clearly as possible:

This complaint is filed based on my honest belief that  has engaged in conduct involving one or more of the following (mark all that apply):

Harassment based on my sex (including gender identity, sexual orientation, and pregnancy, childbirth or any related medical conditions.

Retaliation based on:

Suggested resolution/desired outcome:

I agree that all of the information on this form is accurate and true to the best of my knowledge.

Complainant Signature: 


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