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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): |
_____________________________________________________ _____________________________________________________ _____________________________________________________ |
Nature of discrimination, harassment, or bullying alleged (check all that apply):
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Age |
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Physical Attribute |
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Sex |
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Disability |
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Physical/Mental Ability |
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Sexual Orientation |
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Familial Status |
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Political Belief |
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Socio-economic Background |
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Gender Identity |
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Political Party Preference |
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Other – Please Specify: |
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Marital Status |
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Race/Color |
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National Origin/Ethnic Background/Ancestry |
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Religion/Creed |
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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: __________________________
