|
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 |
|
Race / Color |
|
|
Disability |
|
Sex |
|
|
Religion / Creed |
|
|
|
|
Marital Status |
|
Sexual Orientation |
|
|
National Origin/Ethnic Background/Ancestry |
|
Socio-economic Background |
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: __________________________
