California Harassment Reporting Form

[Company Name] is committed to providing a work environment that is free of unlawful harassment. In furtherance of this commitment, [Company Name] strictly prohibits all forms of unlawful harassment.  

If an employee feels that he or she is being harassed in violation of the company's Discrimination and Harassment Prevention policy [attach or hyperlink policy] by another employee, supervisor, manager or third party doing business with [Company Name], the employee should immediately contact [Supervisor/ Other Job Title] at [insert telephone number] or [Human Resources/Other Job Title] at [insert telephone number]. [Note: It is a best practice to include at least two reporting persons.]

Employees' notification to [Company Name] is essential in preventing workplace harassment. Employees may be assured that they will not be penalized in any way for reporting a harassment or discrimination problem. It is unlawful for an employer to retaliate against employees who oppose the practices prohibited by the California Fair Employment and Housing Act (FEHA). Similarly, the company prohibits employees from hindering its internal investigations or its internal complaint procedure.

To report incidents, employees may use the form below.

Report of Harassment Form (to be completed by employee)

Name:                                                                                                            

Position:                                                                                                         

Job title:                                                                                                          

Department:                                                                                                   

Work telephone number:                                                                               

Date(s) and time(s) of alleged incident:                                                         

Name of person you believe harassed you or another person:

If the alleged incident was directed at a person other than you, please identify the other person:

Please describe as clearly as possible what happened, including what was said and what, if any, physical contact occurred.  Please attach additional pages, if needed.

Please describe how you or the person at whom the incident was directed responded or reacted to the incident, including what was said.

Where did the incident occur?

Were there any witnesses?  If so, please list their names.

Please provide any other information that you believe will assist [Company Name] in investigating this incident.

By my signature below, I confirm that I am submitting this report in good faith and the information provided above accurately reflects my recollection of the incidents related to my complaint. 

______________________________                                    _______________
Signature                                                                                 Date

Return this form to ______________________

​