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):
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:_______________
Approved: 4-21-25 Reviewed: 7-21-25 Revised: 7-21-25
