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Name of Witness: |
_____________________________________________________ |
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Date of interview: |
_____________________________________________________ |
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Date of initial complaint: |
_____________________________________________________ |
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Name of Complainant (include whether the Complainant is a student or employee): |
_____________________________________________________ _____________________________________________________ |
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Date and place of alleged incident(s): |
_____________________________________________________ _____________________________________________________ _____________________________________________________ |
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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: ________________________
Revised: 08/11/2025
Reviewed: 08/11/2025
