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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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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 discrimination, harassment, or bullying alleged (check all that apply):
q Race
q Religion
q Color
q Sexual Orientation
q National Origin
q Age
q Sex
q Actual or potential parental, family or marital status
q Disability
q Pregnancy or related conditions
q 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: __________________________
