Anti-Harassment Event Form

Anti-Harassment Event Form

Your Name and Contact Information (optional)

Emergency Contact (optional)

Email (optional)

I am reporting as a person who has experienced harassment:*

Yes

I am reporting as a witness(es) to harassment:*

Yes

Date of the incident:*

Time of the incident:*

Location of the incident:*

Name(s) of accused:*

Please be specific

Type of conduct*

Check all that apply

Select

Other (if applicable)

Describe the incident(s) as clearly as possible. Include a full description of the events, verbal statements (threats, requests, demands, etc.), the location and what, if any, physical contact was involved.*

List any witness(es) who were present:

How did the witness(es) react (if present)?

How did you react?*

Describe the harm you have suffered as a result of the event. Include a description of physical evidence (if any)

What contact, if any, did you have with the accused prior to the event?

What is your desired outcome of the investigation?*

I hereby certify that the information I have provided in this form is true, correct and complete to the best of my knowledge.*

I agree

I do not agree

I am willing to cooperate fully in the investigation of my complaint and provide whatever evidence is deemed relevant.*

I agree

Other

Other:

Send me a copy of my responses

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