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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 ________________________________