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: __________________________
