Term and Condition Notification of Harassment Form

Organizational Notification of Harassment Form

Please use this web form to submit a notification of a PI's or Co-I's placement on administrative leave or a finding of harassment to the National Aeronautics and Space Administration (NASA) Office of Diversity and Equal Opportunity.

Only the identification of the PI or Co-I is required. Personally identifiable information regarding any complainants or other individuals involved in the matter must not be included in the notification.

This form also should be used by subrecipients to provide any requisite notifications to NASA.

Paperwork Reduction Act Statement:

This information collection meets the requirements of 44 U.S.C 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. The OMB control number for this information collection is 2700-xxxx and it expires on xx/xx/xxxx. We estimate that it will take about 60 minutes to read the instructions, gather the facts, and answer the questions. You may send comments on our time estimate above to civilrightsinfo@nasa.gov. Send only comments relating to our time estimate to this address.

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NASA Award Numbers: *

Name of Principal Investigator (PI/Co-I) being reported: *

Awardee Information

Awardee Name: *

Awardee Address: *

Authorized Organizational Representative (AOR): *

AOR Title: *

AOR Phone: *

AOR Email: *

DUNS Number: *

Type of Notification: * Please select one of the following.

Finding/Determination that the reported individual has been found to have violated awardee policies or codes of conduct, statutes, regulations or executive orders relating to sexual harassment, other forms of harassment, or sexual assault;

Or

Placement by the awardee of the reported individual on administrative leave or the imposition of any administrative action on the PI or any Co-I by the awardee relating to any finding/determination or an investigation of an alleged violation of awardee policies

Explanation/Description of Events: *

Submit 

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