Discrimination and/or Harassment Reporting Form

Western University
Equity & Human Rights Services
Discrimination and/or Harassment Reporting Form

This form is to be used to report behaviour that may contravene Western’s Policy on Discrimination and Harassment. The procedure for making a report is outlined at Section VII 1 and 1.01 of Western’s Non-Discrimination and Harassment Policy – Administrative Procedures (and similar sections within employee agreements). Please note that submitting this form does not mean that action will necessarily be taken. In most cases, you will be offered a confidential consultation with Equity & Human Rights Services (EHRS). EHRS will normally respond to this report within 48 hours (2 working days).

The information you submit will be sent to EHRS via email. If you prefer, you can print a PDF version of this form, fill it out by hand and send it to our office via campus mail.

All reports are maintained as per the practices of Equity & Human Rights Services (EHRS), including confidentiality and file retention. Should you require this form in an alternate format, or need assistance completing this form, please contact EHRS at 519-661-3334.

Please note EHRS does not provide copies of this completed form. Please ensure you print and retain a copy for your own records, if desired.

* - required
Date of this report:
*First Name:
*Last Name:
*Email:
Department:
Phone:

*Preferred contact method:

Phone

Your role at Western:
(most relevant to this report)

Union/Association Affiliation:
(if applicable)

*What best describes your reason for making this report?

Please provide a brief summary of your concerns relating to harassment and discrimination.
Include any steps you’ve taken to address the concerns.

Please provide the names of other parties involved.

Please provide the names of witnesses and/or Academic and/or Administrative Leaders with knowledge of the concerns.

How did you learn about EHRS?		Western's website
		Referred by a supervisor or other Western leader
		Through a training session or workshop
		Word of mouth by a friend/colleague
		Other:

By submitting this completed form, I acknowledge that this information will be maintained as per the confidentiality & file retention practices of Equity & Human Rights Services.

(NOTE: If you wish to retain a copy of this information for your records,
please print this page BEFORE you click the Submit button.)