Name of Witness:______________________________________________________
Date of interview:______________________________________________________
Date of initial complaint:_________________________________________________
Name of Complainant (include whether the Complainant is a student or employee):
____________________________________________________________________
____________________________________________________________________
Date and place of alleged incident(s):
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Nature of discrimination, harassment, or bullying alleged (check all that apply):
_____Age _____Physical Attribute _____Sex
_____Disability _____Physical/Mental Ability _____Sexual Orientation
_____Familial Status _____Political Belief _____Socio-economic Background
_____Gender Identity _____Political Party Preference _____Other – Please Specify:
_____Marital Status _____Race/Color
_____National Origin/Ethnic Background/Ancestry _____Religion/Creed
Description of incident witnessed:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Additional information:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
I agree that all of the information on this form is accurate and true to the best of my knowledge.
Signature: _____________________________________ Date: __________________________
