Department

First Name

Last Name

Department

Phone Number

Name of the Accused

First Name

Last Name

Relationship of the Accused to the Complainant (manager, co-worker, client, etc.)

If more than one event, please report each event on a separate form

YYYY

Where did the specific event occur?

Please explain the events that occurred

How did you react to the situation? Did you take any action to stop perceived inappropriate behavior?

Describe the harm you have suffered as a result of the event

Were there any witnesses to this specific event? (If yes, please provide their names.)

Is there any physical evidence that supports your complaint? If so, please describe or attach copy of evidence.

What is your desired outcome of the investigation?

Name

The information provided in this complaint is true and correct to the best of my knowledge. I am willing to cooperate fully in the investigation of my complaint and provide whatever evidence Freedom Specialty Services deems relevant.

First Name

Last Name

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