Sexual Harassment/Misconduct Complaint Form If you believe the Church’s policy against sexual harassment and misconduct has been violated, we encourage you either to complete this form on the website, you can personally deliver it or send via certified mail to the Pastor at: Simon Temple AME Zion Church, 5760 Yadkin Road Fayetteville, NC 28303. Upon receipt of this complaint form, the Church will follow the investigation process described in its policy. Should you prefer reporting complaints verbally or in manner other than this form, please contact Rev. Dr. Keith D. Tillett, Pastor at (910) 867-1182 (office) or via email at stmembers@simontemple.com so appropriate steps be initiated for proper investigation of your complaint. General Information Are you a member?*YesNo Your Full Name:* Preferred Communication Method:*PhoneEmail Phone:* Email:* Complaint Please tell us who you believe has violated our policy against sexual harassment/misconduct. Name Of Violator:* Select The Status Of The Violator:*MemberStaffContractor Please describe the conduct or incident(s) that is the basis of this complaint and your reasons for concluding that the conduct violated our sexual harassment policy.* Please provide specific date(s) the alleged misconduct occurred.* Additionally, please advise if the alleged misconduct is continuing?*YesNo Please list the name and contact information of any witnesses or individuals that may have information related to your complaint.* Have you previously complained or provided information (verbal or written) about a violation of the Church’s sexual harassment policy to the Church?*YesNo When and to whom did you complain or provide information?* I have reviewed the Church’s policy against sexual harassment/misconduct and request that the Church investigate this complaint in a timely and confidential manner and advise me of the results of the investigation.*I agree Signature:* Date:* Δ
