Richard J. Gonzalez Richard J. Gonzalez
Richard J. Gonzalez
Employment Lawyer

Harassment Form

Sexual, Racial or Ethnic Harassment in the workplace
or workplace defamation
First Name:       Last Name:
Address:
City:    State:    Zip:
Home Phone:            Work Phone:
Cell Phone:        E Mail Address:
Fax Number:            Date of Birth:
Employer Name:
Your job title:
Date of first harassment:
Date of last harassment:
Describe nature of harassment
or
describe defamatory
statements or writings:
Have you registered
complaints with management?		 Yes  No
If Yes, how many times?
Are you still employed
with this employer?		 Yes  No
If not, last day of work:
Best time and method
of contacting me is:
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©2002 Chicago-Kent College of Law, Illiniois Institute of Technology
565 W. Adams St., chicago, Illinois 60661-3691
Tel 312.906.5079; Fax 312.906.5299

Law Offices: rgonzale@kentlaw.edu