Name of Witness: _____________________________________________________

Date of Interview: _____________________________________________________

Date of initial complaint: _____________________________________________________ _____________________________________________________

Name of Complainant (include whether 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: _________________