Bully, Discrimination and/or Harassment Complaint

First and Last Name:

EIN (if applicable):

Email Address:

Phone Number:

Type(s) of conduct:

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Basis(es) of Harassment

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Date of incident:

Time of incident(s):

Location of incident(s):

Include specifics such as route number, office, etc.

Who was involved in this incident(s)?

Who were witnesses to this incident(s)?

Where did this incident(s) occur?

When did the incident(s) occur?

Why did this incident(s) occur? (If known)

Was this an isolated incident? Or has similar Incidents occurred before?

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Please provide any additional helpful details:

If applicable list date, time, witnesses and attach additional forms if necessary.

Describe how you would like the incident resolved?

Please note: All remedies, including disciplinary action, are within the exclusive and sole discretion of EMBARK.

By typing my first and last name below, I certify the above statements to be true and correct to the best of my knowledge.

Send me a copy of my responses