Harassment Report Form
A Harassment report form is used to make a complaint for any kind of harassment. If a person is harassed by any other individual/organization/institute than he can lodge a complaint to the concerned authority through this form. The form requires details of harassment and personal information of the concerned person.
Sample Harassment Report Form
General Information
Name_____________ Age______ Sex_______
Occupation_________ Company_______
Mailing Address____________ Phone___________ Email________
Report prepared by____________ Designation__________ Phone__________
Report Submitted to: Authority/Agency Name___________
Harassment report Information
Date of harassment____/___/___ Time/Hours_______
Place________
Causes of Harassment_____________
Brief Description of Incident______________________
Type of Harassment: Physical/Mental/Other________________
Any Witness of Incident____________ Name______ Address__________ Phone_________
Impact on Person____________
Any Physical Injury_____________
The first authority to be reported for incident_______________ Date and Time_____________
Any Corrective Measures taken by related authorities____________
Declaration
I hereby declare that above given information is correct in my best knowledge.
Signature of Victim___________ Date of report Submission___/___/___
Witness Statement_____________
Signature___________
Report Recipient Information
Name of Recipient_________ Designation__________
Signature___________
Category: Report Forms
