Sexual Harassment Report & Resources

First name

Last name

Your email address

Your phone number

Date of incident

Time of incident

Location of incident

Was this a one off incident or repeated behaviour?

Who was involved?

What happened, tell us in your own words

Other

Were there any witnesses?

Yes No Not Sure

Immediate impact: How did the incident affect you?

Have you reported this before?

Yes No

Did you report it at the time of the incident?

Yes No

If yes, who did you report it to?

Do you require any immediate support?

Manager discussion Change to working arrangements Employee assistance programme contact details Other (define below)

Other

Do you feel there is any ongoing risk to yourself or others?

Yes No

Declaration (please type your name here as declaration that the informaiton you've supplied is accurate to the best of your knowledge)

Posters