Name of witness:____________________________________________________________________________
Position of witness:___________________________________________________________________________
Date of testimony, interview:____________________________________________________________________
Date on initial complaint: ______________________________________________________________________
Name of Complainant (Include whether the Complaintant is a student or employee): ________________________
___________________________________________________________________________________________
Date and place of alleged incident(s): _____________________________________________________________
___________________________________________________________________________________________
Nature of alleged discrimination, harassment, or bullying (check all that apply):
_____Age _____Physical Attribute _____Sex _____Disability _____Sexual Orientation _____Physical/Mental Ability _____Gender Identity _____Familial Status _____Socio-economic Background _____ Political Belief. _____Marital Status _____Political Party Preference _____Race/Color _____Religion/Creed
_____National Origin/Ethnic Background/Ancestry _____Other – Please Specify:________________
Description of incident witnessed:________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Any other information:__________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
I agree that all of the information on this form is accurate and true to the best of my knowledge.
Signature: ______________________________________________
Date: ____/____ /____