Harassment/Discrimination Report

I declare that the foregoing information is true and correct. I understand that neither I, nor anyone involved in the incident, are to retaliate against the other party. I also have the right not to be retaliated against by the other party involved in this incident. If I feel threatened in any way, or have concerns, I will contact the person in charge of responding to this notification. I hereby certify the information I have provided in this form is true, correct, and complete to the best of my knowledge.