Employment Harassment Questionnaire Please Note: Due to many frequent spam form submissions, we have added captchas to all of our forms. If you forget to fill out the captcha at the bottom of the form, just hit your browser's back button. This should take you back to the version of the form that had all the information filled out. You can then fill out the captcha at the bottom of the form. Also, you may always call us if you prefer.Your NameTelephone Number(s)Email AddressHome AddressCity, State, Zip CodeEmployerHow did you hear about us?phone bookanother attorneybar associationotherEmployment Harassment QuestionnaireTo prove harassment, the nature (what was done), severity, duration (how long did it go on), and location (at work or elsewhere) are all crucial elements. The following questions try to get specific information on these and a few other criteria. Check the boxes which apply and try to provide as much detail as possible.Please note there is no limit to the amount of information you can enter. The boxes will scroll as necessary as you add additional information.Where is the employer located and how many employees does the employer have?Does the employer have a written anti-harassment policy?YesNoIf yes, do you have a copy of this policy?YesNoBasis of harassment?AgeDisabilityRace/National OriginGenderOtherIf other, please describe.Please provide the names and job titles of the person(s) who harassed you.What was the harassment?Spoken (slurs, derogatory terms, inappropriate language)Physical (inappropriate touching, gestures)Other form of harassment (gestures, gazes, etc)If the harassment was spoken, what was said?If the harassment was physical, where and how were you touched?If the harassment was of another kind, please describe it.When did the harassment occur, and how often?Were there any witnesses to the harassment?YesNoIf yes, please provide their name, addresses, telephone numbers and any other contact information.Have you complained or mentioned the harassment to others?YesNoIf yes, to whom have you complained or mentioned the harassment?supervisorupper managementpersonnel/human resourcesco-workersothersWere your complaints spoken or written?spokenwrittenwritten and have copy When and to whom (names and job titles) did you complain?What was the response of the person to whom you complained?What sort of action was taken against the harasser?Took no actionReprimandTerminationSuspensionOtherIf the person who harassed you has harassed others, please provide details of the harassment (including who was harassed, when and where, and the nature of the harassment).Was the employer aware of this earlier, other harassment?YesNoIf yes, how was the employer made aware of this other harassment?What action did the employer take to discipline the other harassment?Took no actionReprimandTerminationSuspensionOtherHas anyone else at this employer previously harassed employees?YesNoPlease provide details of the harassment (including who was harassed, when and where, and the nature of the harassment).What action has the employer taken against other harassment?Took no actionReprimandTerminationSuspensionOtherHas the EEOC or the New Mexico Human Rights Division (HRD) investigated similar complaints against the harasser or employer?YesNoIf yes, who filed the complaints, when was the complaint filed, and what were the allegations?Have lawsuits been filed against the harasser or employer?YesNoIf yes, please describe the nature of the lawsuit, including when it was filed, what court it was filed in, and whether it was filed against the employer or against the harasser.Have you previously complained about harassment at either a prior job, or about a different person at your current job?YesNoIf yes, please describe when the complaint was filed, against whom, and what happened after you had complained.How have you been damaged by the harassment?Lost EarningsPhysical InjuriesNon-Physical (for example, emotional distress)OtherWhat are your goals? What do you want to accomplish?Please describe your damages.Please add any other information you feel is important.
