Jenzabar University

Name

Local Address

Cell Phone:

Local Phone:

Work Phone:

Date of Incident

Time of Incident:

Location of Incident:

Identify the name(s) of the individual(s) against whom you are submitting this complaint:

Please describe the nature of the incident, providing as much detail as possible to assist with the investigation of this complaint.

Please provide the names and contact information of any witness(es):

Name/Status

Address

Telephone #

-

Acknowledgement: By signing this form I understand that this complaint will be investigated, and the alleged harasser(s), any witnesses, and persons of interest will be interviewed. The information provided in this Sexual Harassment Reporting Form is true and accurate to the best of my knowledge.

Complainant

Date

Special Note: Discrimination and Harassment should be reported to the Office of Diversity, Equity and Inclusion in the Mellor Building (lower level) or at: 717-391-1365.