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 _____ Physical Attribute _____ Sex
_____ Disability _____ Physical/Mental Ability _____ Sexual Orientation
_____ Familial Status _____ Political Belief _____ Socio-economic Background
_____ Gender Identity _____ Political Party Preference _____ Other – Please Specify:________ _____ Marital Status _____ Race/Color _________________________
_____ National Origin/Ethnic Background/Ancestry _____ Religion/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: __________________________
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Approved: 12/9/24 Reviewed: Revised: