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):
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
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: __________________________
