ALLIES Harassment Report Form

 

 

 

Person(s) Violated: _________________________________ Date of Report: ________

 

Status at University: Student ___ Faculty ___ Other _____________________________

 

Phone Number: _________________ E-mail address: ___________________________

 

Date of Incident: ___________ Location of Incident: ____________________________

 

Person(s) Initiating Harassment: __________________________ Unknown: _________

 

Group Affiliation of Person(s) Initiating Harassment (If Any): _____________________

 

Detailed Description of Incident: _____________________________________________

 

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Witnesses Present: ________________________________________________________

 

Administrative Response Taken (If Any): ______________________________________

 

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I, ________________________, hereby certify that the information I have provided in

 

this complaint is true, correct, and complete to the best of my knowledge and belief.