Fillable ELIZABETH CITY STATE UNIVERSITY Sexual Harassment Complaint Form

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ELIZABETH CITY STATE UNIVERSITY Sexual Harassment Complaint Form

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900.1.2 [F1]
Adopted: 06/08/10
Page 1 of 1
Submit this form to appropriate Intake person as described in ECSU Policy 900.1.2
ELIZABETH CITY STATE UNIVERSITY
Sexual Harassment Complaint Form
To be completed by Complainant
Name (Complainant): ____________________________________________________________
Status: SPA Employee EPA Employee Student Other Unknown
Name of Alleged Harasser: _______________________________________________________
Status: SPA Employee EPA Employee Student Other
When did alleged incident(s) occur (list date(s) and time(s):______________________________
Where did alleged incident(s) occur: _______________________________________________
List any witnesses: _____________________________________________________________
Witness(es) contact information: __________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
(Attach additional sheets, if needed)
Is there any documentation supporting the alleged complaint: Yes No
If yes, list and attach: ___________________________________________________________
_____________________________________________________________________________
Details of alleged incident(s): ____________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
If additional space needed, complete on reverse side.
Signed: ___________________________________________ Date: ___________________
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ELIZABETH CITY STATE UNIVERSITY Sexual Harassment Complaint Form

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Completed 21 February 2020

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