Harassment Reporting Form

Are you reporting as the victim or as a witness?
Victim
Witness

Contact information

Contact

✕

First Name

Last Name

Email

Phone Number

Date of birth

Gender

Add another person

Phone Number

What is the best way for us to contact you?
Text
Call
Email
Other

How should we contact you?

Victim Full Name

What is the best way to contact the victim?
Phone
Email
Other

Victim Phone Number

Victim Email

Other Contact

Is the victim a minor?
Yes
No

Alleged Harasser

Alleged's Full Name

Alleged's Email

Alleged's Phone Number

Relationship to Victim

Incident Report

Date of Initial Harassment

Approximate Time

Is harassment continuing?
Yes
No
Unsure

How long ago was the last occurrence of harassment?

Can you provide the date of the last occurrence of harassment?

In detail, please provide a description of the harassment. Include names of people, locations, times of day and any other information that you can remember.

Is this your first time filing a complaint against this person?
Yes
No

If "no", please explain by providing a brief explanation of the incident, location, date, and who you reported this to.

If there are any other involved persons (witnesses, victims, harassers, etc.) please provide their name and contact information below.