Name of complainant: ____________________________________________________________
Position of complainant: __________________________________________________________
Name of student or employee target: _________________________________________________
Date of complaint: _______________________________________________________________
Name of alleged harasser or bully: ___________________________________________________
Date and place of incident or incidents: _______________________________________________
_______________________________________________________________________________
Description of misconduct: _________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Name of witnesses (if any): _________________________________________________________
________________________________________________________________________________
Evidence of harassment or bullying, i.e., letters, photos, etc. (attach evidence if possible): ________
________________________________________________________________________________
________________________________________________________________________________
Any other information: _____________________________________________________________
________________________________________________________________________________
I agree that all of the information on this form is accurate and true to the best of my knowledge.
Signature: ______________________________________________
Date: ____________________
