SEXUAL HARASSMENT, EXPLOITATION AND ABUSE REPORTING FORM You have decided to file a report under the Stephen Lewis Foundation’s Policy on the Prevention of Sexual Harassment, Exploitation and Abuse. In order to help in the investigation of the report, please complete as much of this form as you can. Fulsome information is helpful to the investigation process. If you would like assistance in completing this form, please contact a senior staff member of the Stephen Lewis Foundation, or anyone else employed by the SLF or a member of the Board of Directors, with whom you feel comfortable sharing this information. Please note that you have the right to remain anonymous. A. I wish to remain anonymous Your name, should you wish to be identified: Your relationship with the SLF: Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneEmail B. Who is the respondent to the report (the person(s) who you believe has engaged in conduct in contravention of this policy)? (Respondent’s Name): Respondent’s relationship with the SLF: Respondent’s relationship to reporting individual (e.g. colleague, supervisor, other): Respondent’s contact information: C. Who is the recipient of the alleged conduct in contravention of this policy (if not you)? The recipient of the alleged conduct has the right to remain anonymous should they choose.(Recipient’s Name): Recipient’s relationship with the SLF: Recipient’s relationship to reporting individual (e.g. colleague, supervisor, other): SUBSTANCE OF THE REPORTWhere did the incident(s) related to the report happen?Describe the incident(s) leading to the report. As much detail as possible will help in the investigation. This includes date(s) and time(s) of the incident(s) and details of the facts and history of the conduct.Please list the names and contact information of any witnesses to the incident(s).Describe what help/advice you requested and/or received regarding this issue prior to filling this report.Did you report the incident(s) to anyone prior to completing this form? If so, to whom and when did you report the incident(s)?The SLF will take into consideration any thoughts you wish to share with respect to the outcome(s) you expect as a result of an investigation into this report.
