Harassment Complaint Form

Directions: To facilitate the review process, employees who believe they have been harassed are 

strongly encouraged to complete this form. This will provide the reviewer(s) with information that is 

useful in responding as quickly as possible to the complaint. Please fill out this form and return it to 

the Human Resources Division (HRD), Attn: April C. Lane, Human Resources Specialist (ER). If you 

require additional space, please use a blank sheet of paper.

Background Information

Date:

Your Name: Department:

Immediate Supervisor: 

Name and title of the person against whom allegations of harassment are being made:

Name of person referring the complaint (if different from the person alleging harassment)

What Happened? 

Please briefly describe the incidents and/or behaviors that prompt your complaint. 

When and where did the incidents and/or behaviors that you are complaining about occur? If there 

was more than one incident/behavior, please list each date. If you cannot remember exact dates, 

times or locations, please provide approximations.

Why do you think you are being subjected to the incidents and/or behaviors described above?

Are there any documents (including emails, text messages, etc.) related to what happened? If so 

please list the documents here and attach copies of the documents to this form.

It is FRTIB's policy to provide for a work environment free from all forms of harassment, including sexual 

harassment, and harassment on the basis of race, color, gender, national origin, religion, sexual orientation, 

age, genetic information, reprisal, parental status, or disability.
Harassment Complaint Form

Did you tell anyone about the incidents/behaviors that occurred that you are complaining about? If 

so, list their names and the approximate date/time you told them about the incidents/behaviors at 

issue. 

Is there any other information that you would like the reviewer(s) to know? If so, please provide it 

here: 

How would you like to see the situation resolved?

Would you like to participate in Alternative Dispute Resolution (ADR) _______Yes _________ No

The goal of ADR is to provide a forum where the complaining and responding parties can, with the aid 

of a third party neutral, come to a mutually agreed upon resolution.

Acknowledgment 

To investigate your complaint, it may be necessary to interview you, the alleged harasser(s), and any 

witnesses with knowledge of the allegations or defenses. The Human Resources Division (HRD) will 

notify all persons involved in the investigation that it is confidential. Retaliation against any employee 

who reports a problem or files a complaint of harassment will not be tolerated and should be 

immediately reported to HRD. 

The information provided in this complaint is true and correct to the best of my knowledge. 

____________________________ ___/___/___ 

Employee Signature Date 

What happens next: This form will be referred to the Human Resources (HR) Officer. The HR Officer will 

review your complaint and determine what, if any, action should be taken. Such action may include an 

informal inquiry or formal investigation into the harassment allegations. Any investigation/inquiry will 

be prompt, thorough, and impartial. The HR Officer will advise you of the conclusions reached after the 

investigation or inquiry. If the HR Officer concludes that harassment has occurred, immediate and 

appropriate corrective action will be taken.

Note: An employee who submits this form has not filed an Equal Employment Opportunity (EEO)

complaint. If you believe you may have been subjected to discrimination or retaliation, including 

harassment based on membership in a protected class, you can contact the Agency EEO Program 

Manager to initiate the EEO process. An employee who wishes to file an EEO complaint must contact 

the EEO Program Manager within 45 calendar days of the alleged discriminatory or retaliatory conduct 

or the date they became aware of the discriminatory or retaliatory conduct. Failure to do so may result 

in the dismissal of the EEO complaint.
Harassment Complaint Form

Privacy Act Notice

Authority – The FRTIB is authorized to collect this information pursuant to: 5 U.S.C. § 8474; 29 U.S.C. § 

701 et seq.; 42 U.S.C. § 2000e et seq.; and 5 C.F.R. Part 136.

Purpose – The FRTIB will only use this information to uphold the FRTIB’s Anti-Harassment policy. By 

completing and submitting this form, you are authorizing the FRTIB to use this information to evaluate, 

respond to, and further investigate your allegation your allegations where necessary.

Routine Uses – FRTIB will protect the confidentiality of the information you provide to the extent 

possible, but cannot guarantee complete confidentiality. FRTIB cannot guarantee complete 

confidentiality, because an effective inquiry usually cannot be conducted without revealing certain 

information to the alleged harasser and potential witnesses. However, the information will only be used 

by FRTIB personnel who need the information to assist in reviewing, evaluating, or resolving your 

complaint. 

Disclosure – Furnishing this information is voluntary. However, failure to furnish the requested 

information may delay the completion of your complaint or result in an inability to evaluate your 

allegations. The information contained in this form is confidential, but may be used in a subsequent 

investigation or litigation involving the claims or facts alleged.