Did the employee see a doctor? Yes No

Will the employee be off working days? Yes No

Were there any witnesses to the conduct? Yes No

I believe these facts to be true. I understand that in order for the hotel to fully respond to my report, it may have to investigate by speaking with other employees of the hotel. I also understand the hotel may be required to disclose my report and name in connection with its investigation. However, the hotel will, at all times, act to prevent retaliation in connection with my report. Yes, I give my consent to use my name in investigating my report of harassment. No, I do not wish the hotel to use my name in investigating this report.