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: ____________
