Employee Workplace Harassment & Discrimination Incident Report Form
Would you like to report anonymo
Your Full Name
· · ·
Your Email Address
· · ·
Submit
The Employee Workplace Harassment & Discrimination Incident Report Form provides a safe, structured way for employees to document and report incidents of harassment or discrimination in the workplace. With built-in anonymity options and confidentiality assurances, it encourages employees to come forward without fear of retaliation, helping organizations take swift and fair action.
This template is ideal for HR departments, compliance officers, and business owners who want a consistent, thorough process for capturing incident details. It collects key information including the date, time, location, and type of incident, as well as details about the individuals involved and whether the behavior is part of an ongoing pattern.
By standardizing how incidents are reported, organizations can ensure thorough investigations, maintain legal compliance, and foster a culture of accountability and respect. Get started with this free template today to strengthen your workplace safety and HR processes.
4Pages
23Questions
~8minTo complete
FreeNo credit card needed
Field types
Short Text ×6
Dropdown ×3
Single Choice ×2
Long Text ×2
Full Name
Email
Phone
Date
Time Picker
File Upload
Yes / No
Multiple Choice
termsandconditions
Signature
Questions in this template
Free template
The exact questions included — customize any of them to fit your needs.
Page 1Reporter Information6 questions
Reporter Information
All reports are treated with the utmost confidentiality. You may choose to remain anonymous, but providing your contact details allows our team to follow up with you directly.
1
Would you like to report anonymously?
*Single Choice
2
Your Full Name
Full Name
3
Your Email Address
Email
4
Your Phone Number
Phone
5
Your Department
Dropdown
6
Your Job Title
Short Text
Page 2Incident Details6 questions
Incident Details
Please provide as much detail as possible about the incident. Accurate information helps ensure a thorough and fair investigation.
1
Date of Incident
*Date
2
Approximate Time of Incident
Time Picker
3
Location of Incident (e.g., office floor, meeting room, parking lot, remote/virtual)
*Short Text
4
Type of Incident
*Dropdown
5
Is this an ongoing pattern of behavior?
*Single Choice
6
Detailed Description of the Incident — Describe what happened, including specific actions, words, or behaviors
*Long Text
Page 3Involved Parties & Evidence7 questions
Individuals Involved
1
Name(s) of the Accused Individual(s)
*Short Text
2
Department / Role of the Accused (if known)
Short Text
3
Relationship of the Accused to You
*Dropdown
4
Name(s) of Any Witnesses
Short Text
Supporting Evidence
If you have any documentation, screenshots, photos, emails, or other evidence related to this incident, please upload them below.
6
Have you reported this incident to anyone else previously (e.g., supervisor, HR, union representative)?
*Yes / No
7
If yes, who did you report it to and when?
Short Text
Page 4Resolution & Consent4 questions
Desired Outcome & Acknowledgment
1
What outcome(s) are you seeking?
Multiple Choice
2
Any Additional Comments or Information You Would Like to Share
Long Text
By submitting this form, you affirm that the information provided is truthful and accurate to the best of your knowledge. Filing a knowingly false report may result in disciplinary action. Your organization is committed to a zero-tolerance policy for harassment and discrimination and will investigate all reports promptly and confidentially.
3
I acknowledge that the information I have provided is true and accurate to the best of my knowledge, and I understand this report will be handled in accordance with company policy.
*termsandconditions
4
Your Signature (optional for anonymous reports)
Signature
How to use this template
Click "Use This Template Free" to open it in the FormBuilder editor. From there you can add, remove, or reorder fields with drag-and-drop, switch themes for instant restyling, add your logo, configure email notifications, and set your success message. When ready, publish with a unique link and start collecting responses immediately.
Ready-to-use structure — pre-configured fields out of the box
Applied "Aura" theme — fonts, colors, and layout already set
Mobile-responsive — works on every device without extra configuration
Fully editable with drag-and-drop — change anything in seconds
Free to use on any plan, no credit card required
Use this template
Free to use. Open in the editor, customize, and publish in minutes.
English
Español
Português
Русский
العربية
