|
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): |
_____________________________________________________
_____________________________________________________
_____________________________________________________ |
Description of incident(s) 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: _______________
Approved: 8/8/2016 Reviewed: 07/14/2025 Revised: 07/14/2025