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 ____ Sex

____ Disability  ____ Sexual Orientation

____ Socio-economic Background

____ Marital Status ____ Race/Color

____ National Origin/Ethnic Background/Ancestry ____ Religion/Creed

____ Other – Please Specify: _______________________

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: ____________