Harassment Incident Details

What date did this incident first occur?

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What time did this incident occur on this date?

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What is the name of the employee, supervisor, manager, customer, or client who perpertrated this incident?

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Were there other individuals who were a part of this incident?

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Please list the additional name(s) of the person(s) involved in this incident:

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Did you have any witnesses who were around during the incident?

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Please list the name(s) of the individual(s) who witnessed this incident.

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What type of harassment has occurred?

Please select an option Age Harassment Disability Harassment Gender Harassment National Origin Harassment Pregnancy Harassment Race/Color Harassment Religious Harassment Sexual Harassment

Age Harassment can include for example: Offensive or derogatory remarks about a person's age. Although the law doesn't prohibit simple teasing, offhand comments, or isolated incidents that aren't very serious, harassment is illegal when it is so frequent or sever that it creates a hostile or offensive work environment or when it results in an adverse employment decision (such as the victim being fired or demoted). The harasser can be the victim's supervisor, a supervisor in another area, a co-worker, or someone who is not an employee of the employer, such as a client or customer. For more information on the EEOC's description, please CLICK HERE.

Disability harassment can include negative or offensive remarks or jokes about a person's disability or need for a workplace change, and other verbal or physical conduct based on a person's disability. For more information on the EEOC's description, please CLICK HERE.

Gender-based harassment is unwelcome conduct based on an individual's actual or perceived sex. It includes slurs, taunts, sterotypes, or name-calling as well as gender-motivated physical threats, attacks, or other hateful conduct. For more information on the Office for Civil Rights at the U.S. Department of Health and Human Services, please CLICK HERE.

National Origin Harassment involves unwelcome and offensive conduct in the workplace that is based on an individual's ethnicity or place of origin. The harasser can be your supervisor, a supervisor in another area, a co-worker, or someone who does not work for your employer, such as a client or customer. National Origin harassment can also include ethnic slurs, jokes, offensive or derogatory comments, or other verbal or physical conduct based on an indivdual's national origin. For more information on the EEOC's description, please CLICK HERE.

It is unlawful to harass a person because of that person's race or color. Harassment can include, for example, racial slurs, offensive or derogatory remarks about a person's race or color, or the display of racially-offensive symbols. The law does not prohibit simple teasing, offhand comments, or isolated incidents that are not very serious, harassment is illegal when it is so frequent or severe that it creates a hostile or offensive work environment or when it results in an adverse employment decision (such as the victim being fired or demoted). The harasser can be the victim's supervisor, a supervisor in another area, a co-worker, or someone who is not an employee of the employer, such as a client or customer. For more information on the EEOC's description, please CLICK HERE.

It is illegal to be discriminated against because of the combination of your pregnancy and some other protected category. For more information on the EEOC's description, please CLICK HERE.

It is illegal to harass a person because of his or her religion. Harassment can include, for example, offensive remarks about a person's religious beliefs or practices. Although the law doesn't prohibit simple teasing, offhand comments, or isolated incidents that aren't very serious, harassment is illegal when it is so frequent or severe that it creates a hostile or offensive work environment or when it results in an adverse employment decision (such as the victim being fired or demoted). The harasser can be the victim's supervisor, a supervisor in another area, a co-worker, or someone who is not an employee of the employer, such as a client or customer. For more information on the EEOC's description, please CLICK HERE.

Harassment does not have to be of a sexual nature, however, and can include offensive remarks about a person's sex. For example, it is illegal to harass a woman by making offensive comments about women in general. Both the victim and the harasser can be either a woman or a man, and the victim and harasser can be the same sex. Although the law doesn't prohibit simple teasing, offhand comments, or isolated incidents that are not very serious, harassment is illegal when it is so frequent or severe that it creates a hostile or offensive work environment or when it results in an adverse employment decision (such as the victim being fired or demoted). The harasser can be the victim's supervisor, a supervisor in another area, a co-worker, or someone who is not an employee of the employer, such as a client or customer. For more information on the EEOC's description, please CLICK HERE.

Please describe exactly what was done to you? Please include details of words exchanged between you and the harasser(s), as well as any physical details of what transpired. Please indicate the harasser's name/names when referring to them in your statements.

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Where did this incident occur at your work location? Example: At my desk, Breakroom, Bathroom, Lunchroom etc.

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