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INDIAN AFFAIRS HARASSING CONDUCT ALLEGATION INTAKE FORM (Bureau of Indian Affairs)

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INDIAN AFFAIRS
HARASSING CONDUCT ALLEGATION INTAKE FORM
Adapted from Appendix A of Personnel Bulletin 18-01: Prevention and Elimination of Harassing Conduct
This intake form is to be used by all Indian Affairs management officials to record a report of
harassing conduct. It can be used as a prompt during a conversation with an employee reporting
harassing conduct, and then used to document the conversation after the fact. Gathering as much
information as possible immediately from the individual reporting the alleged harassing conduct
will aid management in swiftly determining the best course of action. Please consult with your
servicing Employee Relations Specialist if you have questions regarding this form.
Management Official Taking the Report
Name: _________________________ Title: ____________________________________
Organization: __________________________________________________________________
Date Information Reported: ___________________________ Time: __________________
Individual Reporting Harassing Conduct
Name: _________________________ Title: ____________________________________
Organization: __________________________________________________________________
Phone: _________________________ Job location: ______________________________
Individuals Allegedly Engaging in Harassing Conduct (if known)
1. Name: _________________________ Title: ____________________________________
Organization: __________________________________________________________________
Phone: _________________________ Job location: ______________________________
2. Name: _________________________ Title: ____________________________________
Organization: __________________________________________________________________
Phone: _________________________ Job location: ______________________________
3. Name: _________________________ Title: ____________________________________
Organization: __________________________________________________________________
Phone: _________________________ Job location: ______________________________
Questions to Ask the Individual Reporting the Harassing Conduct
1. Date(s) of alleged incident(s)/action(s):
2. Please describe specifically the alleged harassing conduct, including the protected status on
which you believe it was based [i.e., race, color, religion, sex (including pregnancy and gender
identity), sexual orientation, national origin, age, disability, family medical history (including
genetic information), status as a parent, marital status, or political affiliation]:
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3. Was this an isolated event or a pattern of similar events or behaviors?
4. Was the harassing conduct directed at you or someone else? If someone else, to whom was it
directed?
5. What was your reaction?
6. How did this conduct or behavior affect you? How did it make you feel?
7. Did you speak to the person who engaged in harassing conduct to ask them to cease? If so,
what was their response?
8. Can you identify other individuals with knowledge of the alleged conduct at issue or other
3
actions/behaviors by the charged individual(s) in the past? (Include observations, what people
heard, and who you told about the events in question.)
9. Are there any documents or physical evidence that may support the claim of alleged
occurrences? If so, please identify them.
10. Do you feel that the alleged harasser(s) is a threat to your safety and well-being or that of
others? If so, how?
11. Have you previously complained about this or related acts of harassing conduct by the same
individual(s) to a supervisor or manager? If so, please identify the individual(s) to whom you
complained, the date(s) of the complaint(s), and the resolution(s), if any.
12. Is there is any other information related to the incident(s)/action(s) or any other information
related to the inquiry that you would like to provide?
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Completed 26 September 2021

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