Dignity Act Harassment Complaint Form

	You may submit this form anonymously by leaving the "Name of Reporter" section blank. Please note: all reports will be investigated to the fullest extent possible. An anonymous report may limit the investigator’s ability to verify information.

	Date of complaint*
	mm/dd/yyyy

	Targeted student(s)

	Name of person(s) committing the alleged harassment

	Date(s) and time(s) of incident(s)*

	Place(s) where incident occurred*

	Description of the harassment*

	Names of witnesses, if any

	By submitting this form, I certify that all statements on this form are accurate and true to the best of my knowledge.

	Name of Reporter (optional)

	email (optional)

	Phone (optional)

	Please click "Done" to submit this form.