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POLICY NO . 13 - 121 Anti -Harassment Page 3 of 3 <br /> Name : <br /> Date : <br /> I wish to complain about the following events . <br /> (Use additional sheets of paper as required) <br /> What action or actions do ,you wish the Hospital to take regarding your complaint ? <br /> I, (name), hereby consent to the Hospital 's conducting a complete <br /> and thorough investigation of the above complaint. I further authorize the Hospital to disclose to others <br /> portions of the information I have provided and may in the future provide, with respect to <br />the <br /> complaint, as certain information may have to be released in order to insure that a <br /> complete <br /> investigation can be conducted. <br /> I acknowledge that I have read and understand the above statements. <br /> Employee Signature Date <br /> http : //web/search?NS -search -page=document&N S -rel -doc -name=/manual s/personnel/ 13 _ 1 05/ 15/2003 <br />