EXHIBIT A – EMPLOYEE HARASSMENT COMPLAINT FORM

(Administrative Rule 512)

Name of complainant                                                                                                                                  

Where did or is the incident(s) occur(ring) (building, grounds)?                                                                      

When did or is the incident(s) occur(ring)? Date                                          Time                                        

Was or is anyone else present at the time the incident(s) occurred or is occuring?                                          

Who was or is involved in the incident(s)?                                                                                                    

What happened or is happening (nature of complaint)?                                                                                  

How does complainant want the incident(s) or complaint resolved?                                                                

Name of person providing information for the form                                                                                       

Name of person completing form                                                                  Date                                      

Signature of complainant                                                                               Date_____________________

AR 512 - Employee Harassment Complaint Form

Action taken:

                 By whom                                                                                   Date                                        

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