Employee Harassment Fact Sheet

EMPLOYEE HARASSMENT FACT SHEET

Use this fact sheet to provide a clear, contemporaneous account of alleged harassment or hostile conduct. Complete every section to the best of your knowledge. Information provided will be used for internal assessment and investigation. If you need additional space, attach extra pages and note them below.

Personal Information

Position Information

Incident Details

Date of incident:    Time (approx.):

Type(s) of alleged conduct (check all that apply):

Is the conduct continuing?   Yes No

Alleged Harasser(s)

Provide name(s), title(s), department(s), and relationship to you. If more than two alleged harassers, attach additional pages.

Witnesses

List any witnesses to the alleged conduct and brief summary of what each witness observed.

Detailed Account / Chronology

Provide a detailed, chronological description of the events. Include dates, times, direct quotes when possible, and actions taken by any party involved.

Evidence and Documentation

Check any evidence types you are submitting or that may exist, and briefly describe or reference attachments.

Actions Taken by Reporter

Prior to completing this form, did you report this incident to anyone? If yes, provide name(s), title(s), and dates.

Impact and Safety Concerns

Resolution Requested

Legal Disclosures and Certifications

Equal Opportunity and At-Will Employment: The company prohibits unlawful harassment and will evaluate complaints in accordance with company policy. Nothing in this fact sheet alters the employment-at-will relationship, where applicable, unless an authorized written agreement states otherwise.

Confidentiality and Investigation: The company will attempt to preserve confidentiality to the extent possible consistent with a thorough investigation. Relevant information may be shared with witnesses, alleged parties, and others as required to conduct an effective inquiry. Certain disclosures are required by law and the company will comply where necessary.

Non-Retaliation: The company prohibits retaliation against individuals who report harassment in good faith or participate in an investigation. If you believe you have experienced retaliation, report it promptly.

Authorization to Investigate: By signing below, I authorize the company and its designated representatives to investigate this complaint, to interview witnesses, to review relevant records including electronic communications where permitted, and to take any interim actions deemed appropriate for safety or preservation of evidence.

Certification: I certify under penalty of disciplinary action that the information provided on this fact sheet and any attachments is true and complete to the best of my knowledge. I understand that knowingly providing false information may result in disciplinary action up to and including termination.

Employment History (Required)

Provide the two most recent employers. This information may be used to corroborate timeline or contacts.

Education

References (Professional)

Provide three professional references who can speak to your character or job performance.

Authorization to Contact and Background Check

I authorize the company to contact witnesses, references, prior employers, and other relevant parties as part of the investigation. I further authorize review of relevant records, including electronic communications, personnel files, and security logs where permitted by law.

I authorize the investigation and contact described above.

Reporter Certification

I certify that the information provided is true, accurate, and complete to the best of my knowledge. I understand that the company will rely on this information during its assessment and any subsequent action. I understand that making knowingly false statements may subject me to disciplinary action.

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