Fresco Pizza ALLEGED SEXUAL HARRASSMENT response form

							                             ALLEGED SEXUAL HARRASSMENT
                                  RESPONDENT FORM
                                                                                      Date: __________
                                                                                      Time: __________
Person filing Reponse Report:_____________________________
Address:          ____________________________________________________________
Telephone Number: ______________________________________________________

Date of Alleged Harassment Incident:          ________________
Report of Incident. Please state what happened on the incident in question. Answer the questions who,
what, where, how and state all pertinent facts. (You may use the back of this form if necessary). Give as
many specifics as possible.
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Please list all others who may have knowledge regarding this matter (Give names, addresses, and phone
numbers, if known. State if they are employees or customers.) Briefly state what the persons know of this
incident or of anything related to this incident:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

What action do you believe Fresco Pizza should take in order to resolve this issue?       _____________

_____________________________________________________________________________________
_______________________________________________________________________

The foregoing information is true and correct to the best of my knowledge.

         Person filing report: __________________________
                                                  (Signature)


         Printed Name:                 __________________________

Signature and date of Supervisor receiving report:

         _________________________________                              _______________________
                           Signature                                                     Date