| Name of Witness | |
|---|---|
| Date of Interview | |
| 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: | |||
| 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 | ________________________________ |