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):
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
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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: _________________________
Approved:_______
Reviewed:________
Revised:
