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:
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Yes
No
I am reporting as a witness(es) to harassment:
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Yes
No
Date of the incident:
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Time of the incident:
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Location of the incident:
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Name(s) of accused:
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Please be specific
Type of conduct
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Check all that apply
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.
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List any witness(es) who were present:
How did the witness(es) react (if present)?
How did you react?
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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?
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I hereby certify that the information I have provided in this form is true, correct and complete to the best of my knowledge.
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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.
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I agree
Other
Other:
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