Richard J. Gonzalez
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Sexual, Racial, or Ethnic Harassment in the Workplace or Workplace Defamation
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Harassment Form
Harassment Form
First Name
(required)
Last Name
(required)
Address
City
State
Zip
Home Phone
Work Phone
Cell Phone
Email
(required)
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 the 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:
Submit
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