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Name of Witness: |
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Date of interview:
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Date of initial complaint:
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_____________________________________________________ |
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Name of Complainant (include whether the Complainant is a student or employee): |
_____________________________________________________
_____________________________________________________ |
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Date and place of alleged incident(s): |
_____________________________________________________
_____________________________________________________ |
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Nature of harassment, or bullying alleged alleged (check all that apply):
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Age |
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Political Belief |
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Disability |
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Political Party Preference |
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Familial Status |
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Race/Color |
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Gender Identity |
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Religion/Creed |
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Marital Status |
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Sex |
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National Origin/Ethnic Background/Ancestry |
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Sexual Orientation |
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Physical Attribute |
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Socio-economic Background |
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Physical/Mental ability |
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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: __________________________