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Sample Formal Complaint Form

This is a sample complaint form. Your workplace may use a different form or not have a set form for making a complaint.

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

Sample Employer Harassment Complaint Form

Complainant Information


Phone Number

Work Unit:

Job Title:

Supervisor’s Name:

Supervisor’s Phone Number:

Witness Information

List names of possible witnesses:



Phone Number:

Information about the individual(s) you feel has/have harassed you:

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

Date of incident:

In your opinion is the harassment based on any of the following? Check all that apply to your situation.

_ 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

If not based on any of the above grounds, is the harassment based on one of the following:

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: _______________

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