I am a:
Provide Any Details:
1. Do you believe you have ever been subjected to sexual harassment while employed here?
2. When was the most recent incident? Check all that apply
I am currently experiencing a sexual harassment problem
less than six months ago
more than six months ago
less than 6 years ago
provide dates on which you were sexually harassed
was the sexual harassment ongoing (pervasive)
was the sexual harassment on one specific date (severe)
3. Who harassed you? Check all that apply.
higher management official
client(s), vendor(s), customer or other non-employees
other (specify below)
4. What was the nature of the harassment? Check all that apply.
unwelcome sexual relations
unwelcome sexual relations in exchange for not being fired
unwelcome sexual relations in exchange for promotion
unwelcome physical contact (touching, pinching, brushing against your body, criminal conduct, assault, battery, rape )
commenting about your appearance or body
obnoxious or unwanted telephone calls
obnoxious or unwanted letters or other correspondence
sexually suggestive objects or photographs or pornographic videos displayed in the workplace
offensive jokes or innuendos
5. What was your response to the harassment? Check all that apply.
resolved the problem by talking to the harasser
left the job by quitting or demanding a transfer
complained to management in writing and nothing was done
complained to management verbally and nothing was done
complained to the personnel office
filed a grievance through the union
filed charges with the state anti-discrimination agency
filed discrimination charges with the federal Equal Employment Opportunity Commission
consulted an attorney and filed a lawsuit and am seeking a new attorney
6. Was any adverse action threatened or taken against you because you complained about the harassment or because you refused to submit to it?
Yes. Check all that apply.
denied salary increase
given a poor performance evaluation
7. Do you have an employee handbook?
8. Were you given a copy of the employee handbook to keep?
9. Is there a formal procedure that your employer provides for a method of complaining about sexual harassment?
10. Are there signs posted at your place of work that give notice that federal law prevents discrimination including sexual-harassment?
11. How many people were employed by the company at the time you were sexually harassed?
1 to 3 including myself
4 to 14 including myself
15 to 99 including myself
12. What was the outcome of your effort to stop the harassment?
13. Do you have any documents, photographs, text messages, saved voice mails or the like that will support or confirm any potential claim that you might bring? If so give a short description
14. Are you seeing a psychiatrist or a psychologist in connection with your being sexually harassed? If so, provide their name, address and phone number below: