|
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: __________________________
