Sample Formal Complaint Form

Even though it may differ in your workplace this sample can help you understand the type of information needed for a complaint.

Name:

Phone Number

Work Unit:

Job Title:

Supervisor’s Name:

Supervisor’s Phone Number:

List names of possible witnesses:

Name:

Position:

Phone Number:

Name of person(s) against whom this complaint is made:

Date of incident:

_ Sexual Orientation

_ Nationality

_ Place of Origin

_ Physical Weight/Height

_ Marital Status

_ Religion

_ Disability

_ Family Status

_ Colour

_ Ancestry

_ Sex

_ Age

_ Creed

_ Race

_ None of the Above

a) Repeated incidents that have caused you to be humiliated or intimidated. Yes___ No____

b) A single serious incident that has had a lasting harmful effect on you. Yes___ No___

c) Sexual Harassment Yes___ No___

In your own words, describe the conduct, comments or display you found objectionable. Give details of date and location of the incident(s) that is/are the basis of your complaint.

What type of resolution do you seek? (e.g., supervisor to direct or counsel person to correct conduct; facilitated meeting with alleged harasser; apology; workshops or training sessions; mediation; or other.)

I hereby confirm the statement(s) contained in this complaint are true to the best of my
knowledge. I understand a copy of this complaint will be provided to the alleged harasser(s) for
the purpose of investigating this complaint.

Signature: ______________________________ Date: ______________

I acknowledge receipt of this complaint.

Supervisor’s Signature: ____________________ Date: _______________