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SU-133 Sexual Harassment Complaint Reporting Form
**To be completed by Supervisor/Administrator**
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Email
*
Your email
Date
*
MM
/
DD
/
YYYY
Name
*
Your answer
Job Title
*
Your answer
Location
*
Your answer
Phone Number
*
Your answer
Name of Complainant
Your answer
Complainant
*
Student
Employee
Non-Employee
Parent/Guardian
Required
Name of Person Against who Complaint is Made
*
Your answer
Classification of Respondent
*
Student
Employee
Non-Employee
Parent/Guardian
Required
If they are a student or employee, what is their ID number and their job location or school site
Your answer
Date when Complaint was brought to your attention
*
MM
/
DD
/
YYYY
Nature of complaint:
The following is a description of the grounds for the complaint that was stated by the complaining party:
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Your answer
Was Complaint Substantiated?
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Yes
No
Required
If complaint was substantiated, what corrective Action was taken?
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Your answer
Date corrective Action was taken
*
MM
/
DD
/
YYYY
Additional Information
Your answer
Information about all complaints of Sexual Harassment must be forwarded to the Affirmative Action Office to maintain district logs pursuant to ED Code 253 (A) within 7 working days of resolution.
**Response is not Required**
Your answer
A copy of your responses will be emailed to the address you provided.
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