Sexual Harassment Contact Form

Name

Email Address

Phone Number

Business Phone

Cellular or Pager

Address

City

State

Zip

Can you be contacted at work?

Yes No

Does this situation involve an employer?

Yes No

If so, please provide the name and address of the employer involved:

Are you a current _____ of this employer?

employee former employee job applicant prospective employee

If this situation does not involve an employer, please provide the name and address of the party involved, and that party's relationship to you:

Describe your situation, including any relevant dates:

Have you made a complaint about your situation to any governmental agency?

Yes No

If yes, provide the name of the agency, the date you made your complaint, and the final result, if any, of your complaint:

Please provide the names and addresses (if known) of the other people involved, and their relationship to you, if any:

Do you have any documents that could help explain your situation?

Yes No

If yes, list those documents and their dates:

Are there other documents that you do not have access to that could be of assistance?

Yes No

If yes, list those documents and their dates and locations (if known):

Describe how this situation has impacted you:

Describe what you would like to happen to resolve your issue (your preferred outcome):

Have other attorneys worked on this matter?

Yes No

If yes, provide names, addresses, and a brief description of their involvement:

Special concerns:

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