TEAMSTERS LOCAL UNION NO.

769

HARASSMENT COMPLAINT FORM

Name of Complainant: _____________________________________________

Date of Complaint: ________________________________________________

Supervisor: ______________________________________________________

Complaint Made To: ______________________________________________

Details of Complaint: ______________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

Action Requested to Resolve the Complaint: ___________________________

_________________________________________________________________

_________________________________________________________________

I, ____________________________, the Complainant, wish to lodge a complaint of Workplace

Harassment and/or Discrimination. I hereby, authorize the Department Head to conduct whatever
investigations are necessary to reach a satisfactory resolution to the complaint. I also, hereby agree
to participate in this investigation to the best of my ability.

Date: ___________________ Signature of Complainant: ___________________________________

SEND COPY TO: Teamsters Local Union No. 769, and HR Department.