Investigation of Harassment Claim. This form is to be used for investigating a claim of harassment. Upon completion, this information should b e submitted immediately to the Title IX Coordinator Dr. Neil Nuttall in order to activate a thorough and
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This form is to be used for investigating a claim of harassment. Upon completion, this information should
be submitted immediately to the Title IX Coordinator Dr. Neil Nuttall in order to activate a thorough and
prompt investigation. Information regarding alleged harassment shall be kept confidential to every extent
Complainant : Job Title (employees only):
Phone Number: - - Department:
Alleged Harasser: Phone Number: - -
Description of relationship of complainant to harasser:
Complainant Statement: Ask party to describe harassment on Form (A) in precise terms. If verbal, ask them to record the entire
conversation. If physical, describe the specific conduct.
Has there been a prior incident regarding this harasser ? YES NO If so, when and what
happened? Was a complaint filed? YES NO (List date of any prior reports on file)
Witness Statements (Have each witness complete Form (B) in precise terms. Describe who, what, when, where and how. State all
pertinent facts and any conversations in detail. Document all eye witness accounts.
Was medical treatment sought? YES NO
Recommended Next Steps:
Recorded By: Date:
Received By: Date:
Dr. Neil Nuttall, NCMC President and Title IX Coordinator